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An examination of factors that contribute to the shortage of behavioral health providers in the United States Navy

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An examination of factors that contribute to the shortage of behavioral health providers in the United States Navy

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Content An Examination of Factors that Contribute to the Shortage of Behavioral Health Providers
in the United States Navy
by
Michael Jacob Ortiguero
Rossier School of Education
University of Southern California
A dissertation submitted to the faculty
in partial fulfillment of the requirements for the degree of
Doctor of Education
August 2024

© Copyright by Michael Jacob Ortiguero 2024
All Rights Reserved

The Committee for Michael Jacob Ortiguero certifies the approval of this Dissertation
Marcus Pritchard
Monique Datta
Helena Seli, Committee Chair
Rossier School of Education
University of Southern California
2024

iv
Abstract
This study addresses the critical shortage of behavioral health (BH) providers in the United
States Navy and examines its consequential impact on Sailors and their families. Employing
Bronfenbrenner's ecological systems theory as a theoretical framework, this research seeks to
identify potential strategies for expanding BH treatment amidst a global shortage of BH
providers. Through semi-structured interviews, the study explores the experiences and
perspectives of uniformed and civilian BH providers working at a Navy medical treatment
facility (MTF), comprehensively examining the factors contributing to their scarcity. It also
assesses the obstacles and opportunities presented by the Navy, proposing strategies to enhance
BH services for Navy beneficiaries. The anticipated outcomes of this study will contribute to the
development of evidence-based solutions aimed at mitigating the impact of the BH provider
shortage on the well-being of Navy personnel. The rising rates of BH issues among Sailors
highlight the significance of this research. Additionally, the application of ecological systems
theory provides a detailed understanding of the individual and environmental factors influencing
BH provider behavior, informing targeted interventions that aim to improve the overall wellbeing of Navy families.
Keywords: behavioral health (BH), provider, Sailor, ecological systems theory,
recruitment, retention, United States Navy, military treatment facilities (MTFs)

v
Dedication
I dedicate this work to Jesus without Him, none of this would have been possible.
I extend my deepest gratitude to my cherished parents, whose steadfast love and support have
been the cornerstone of my journey. To my dear wife, your love, patience, and belief in my
endeavors have been my sanctuary. To my precious son, you are my favorite person in the world.
The amazement you bring to me each day has been my greatest encouragement. To my
grandparents, Leopoldo and Corazon Ortiguero, whose educational journeys paved the way for
me, I owe a profound debt of gratitude. To my late uncles, Julius and George Ortiguero; although
your lives were tragically cut short, the profound impact you had on my life continues to inspire
me daily. I am forever grateful to have had you both, you were the best uncles I could ask for.
To my Navy comrades, I am immensely grateful for your impact over the past two
decades. Thank you to the leaders who led me with wisdom and integrity, shaping me into the
professional I am today. I am equally thankful for the privilege of leading some of the finest
individuals; your trust and diligence under have been profoundly humbling and rewarding.
To the legendary Trojans like Pete Carroll, Matt Leinart, Reggie Bush, and the Trojan
heroes of USC's early 2000s football, your storied victories were a beacon of hope that resonated
with me across continents. Your legacy is forever interwoven into the fabric of my story.
To my dissertation team, classmates, and professors, I extend my deepest gratitude for
your wisdom, insight, encouragement, and collaboration, which have been instrumental in
shaping my scholarly journey. Thank you all sincerely, from the bottom of my heart. Fight On!

vi
Acknowledgments
First and foremost, I want to extend my heartfelt thanks to Jesus for guiding me to this
point, a place I never imagined I would reach. Your boundless grace and unwavering guidance
have been my constant source of strength, inspiration, guidance, and unwavering hope.
I am deeply thankful to my family, whose unwavering support and patience have meant
everything to me. Their involvement and encouragement have sustained me during challenging
times and inspired me every step of the way. I just wanted to make you proud of me.
I am immensely grateful to the esteemed faculty of the University of Southern California,
whose exceptional guidance has been pivotal in shaping my scholarly development. Dr, Monique
Datta, Dr. Helena Seli, Dr. Jennifer Phillips, and Dr. Marcus Pritchard, your invaluable
mentorship and rigorous academic support have expanded my intellectual horizons and fostered
personal growth.
To my Trojan colleagues and friends—Sandra, Lesley, Dereck, DiCarie, and Damian—
your support and shared wisdom have been indispensable. Our collective endeavors and
interactions have not only enriched my academic experience but my personal life as well. The
bonds of friendship we have formed during this journey are treasured deeply, and I am confident
that these relationships will endure well beyond our academic pursuits, sustaining us through
future endeavors and continuing to inspire personal and professional growth.
I owe a deep debt of gratitude to all those who contributed their expertise and knowledge,
directly or indirectly, to this study. This dissertation adheres to the highest standards of research
integrity, with all relevant registration details and data-sharing frameworks duly observed. I am
profoundly thankful for the unwavering support and invaluable contributions that made this work
possible.

vii
Table of Contents
Abstract.......................................................................................................................................... iv
Dedication ....................................................................................................................................... v
Acknowledgments.......................................................................................................................... vi
Chapter One: Introduction to the Problem of Practice.................................................................... 2
Background of the Problem ............................................................................................................ 3
Organization Context and Mission ................................................................................................. 5
Purpose of the Study and Research Questions................................................................................ 6
Importance of the Study.................................................................................................................. 6
Overview of Theoretical Framework and Methodology ................................................................ 8
Definitions....................................................................................................................................... 9
Organization of the Dissertation ................................................................................................... 10
Chapter Two: Review of the Literature ........................................................................................ 11
Background on the Shortage of Behavioral Health (BH) Providers in the Navy ......................... 11
Defining BH Providers in the Navy.......................................................................................... 13
Uniformed Navy BH Providers ................................................................................................ 14
Civilian BH Providers............................................................................................................... 15

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The Global and National Shortage of BH Providers ................................................................ 16
Factors that Contribute to the Shortage of BH Providers in the Navy.......................................... 17
Recruitment of BH Providers.................................................................................................... 18
Retention Shortfalls for BH Providers...................................................................................... 23
Uniformed BH Provider Promotion Issues............................................................................... 27
Impact of Shortage of BH Providers to the Navy ......................................................................... 28
Access To Care ......................................................................................................................... 30
Substance Use Disorders........................................................................................................... 31
Suicide....................................................................................................................................... 33
Potential Solutions to the Shortage ............................................................................................... 34
Hiring ........................................................................................................................................ 31
Telehealth.................................................................................................................................. 37
Network Referrals..................................................................................................................... 38
Bronfenbrenner’s Ecological Systems Theory Model.................................................................. 40
Conceptual Framework................................................................................................................. 42
Ecological Approaches to BH Care Settings ............................................................................ 43
Ecological Approach to BH Programs...................................................................................... 44
Conclusion .................................................................................................................................... 49
Chapter Three: Methodology........................................................................................................ 51

ix
Overview of Methodology............................................................................................................ 51
The Researcher.............................................................................................................................. 52
Data Source: Interviews............................................................................................................ 53
Participants................................................................................................................................ 54
Instrumentation ......................................................................................................................... 55
Data Collection Procedures....................................................................................................... 56
Data Analysis............................................................................................................................ 57
Credibility and Trustworthiness.................................................................................................... 59
Ethics............................................................................................................................................. 61
Limitations and Delimitations.................................................................................................. 65
Limitations................................................................................................................................ 66
Delimitations............................................................................................................................. 67
Chapter 4: Findings....................................................................................................................... 64
Participants.................................................................................................................................... 65
Research Question 1: How Does the Navy’s Shortage of BH Providers Impact Existing BH
Providers’ Capacity to Meet the Needs of Their Existing Patients and to Accept New Patients? 67
Theme 1: Overwhelming Workload and Burnout .................................................................... 67
Theme 2: Difficulties in Delivering and Maintaining High-Quality Patient Care.................... 68
Research Question 2: How do the Various Levels of the Navy System Present Both Obstacles
and Opportunities for Hiring New BH Providers and Retaining Current BH Providers? ............ 70

x
Obstacles for Hiring New BH Provides and Retaining Current BH Providers ........................ 70
Theme 3: Workplace Discontent .............................................................................................. 70
Theme 4: Bureaucratic Inefficiencies with the Civilian Hiring Process................................... 72
Theme 5: Promotion Challenges for Uniformed BH providers................................................ 73
Opportunities and Strategies for Hiring New BH Providers and Retaining Current BH
Providers................................................................................................................................... 75
Theme 6: Competitive Compensation and Incentives .............................................................. 76
Theme 7: Enhancing Recruitment through Community Outreach Initiatives .......................... 77
Theme 8: Supportive Policies for Pregnant BH Providers ....................................................... 78
Research Question 3: What Strategies Can the Navy Health System Implement to .................... 80
Enhance BH Care for Navy Beneficiaries Despite the Global ..................................................... 80
Shortage of BH Providers? ........................................................................................................... 80
Theme 9: Streamlining Administrative Processes.................................................................... 80
Theme 10: Hiring More Paraprofessionals............................................................................... 82
Theme 11: Innovative Approaches to BH Services in the Navy .............................................. 83
Summary of Findings.................................................................................................................... 84
Chapter Five: Discussion and Recommendations......................................................................... 86
Discussion of Findings.................................................................................................................. 86
Consequences of Excessive Workload on BH Providers ......................................................... 87
Systemic Obstacles to BH Provider Recruitment and Retention.............................................. 87

xi
Compensation as a Lever in BH Workforce Expansion ........................................................... 88
Innovative Solutions for Broadening Access to Behavioral Health in Response to BH Provider
Shortages................................................................................................................................... 89
Recommendations for Practice ..................................................................................................... 90
Recommendation 1: Streamline Administrative Processes through Artificial Intelligence (AI)
Integration ................................................................................................................................. 91
Recommendation 2: Expand Telehealth Services..................................................................... 91
Recommendation 3: Enhance Recruitment and Retention through Competitive Compensation
................................................................................................................................................... 92
Recommendation 4: Develop and Utilize Paraprofessionals.................................................... 94
Recommendation 5: Implement Supportive Policies for Pregnant BH Providers.................... 94
Integrated Recommendations.................................................................................................... 95
Streamlining Administrative Processes Through AI Integration.......................................... 95
Expanding Telehealth Services............................................................................................. 96
Enhancing Recruitment and Retention Through Competitive Compensation...................... 96
Supporting Pregnant BH Providers....................................................................................... 98
Implementation Sequence..................................................................................................... 98
Limitations and Delimitations....................................................................................................... 99
Limitations.............................................................................................................................. 100
Delimitations........................................................................................................................... 101
Recommendations for Future Research ...................................................................................... 103

xii
Implications for Equity ............................................................................................................... 104
Conclusion .................................................................................................................................. 104

1
List of Figures
Figure 1: Conceptual Framework............................................................................................... 49

2
Chapter One: Introduction to the Problem of Practice
The distinctive dangers and persistent threats encountered in the United States Navy lead
to considerable psychological challenges for both Sailors and their supporting families. These
burdens frequently manifest as mental health disorders, contributing to distress and impaired
functioning in social, work, and home environments (Inspector General, 2020; Navy Health of
the Force, 2022; Meadows et al., 2018). Given the demanding and stressful nature of Navy life,
comprehensively addressing these mental health challenges is imperative. The Substance Abuse
and Mental Health Services Administration (SAMHSA) defines behavioral health (BH) as the
promotion of mental health, resilience, and well-being, alongside the treatment of mental and
substance use disorders, and the support of those recovering from these conditions and their
families (SAMHSA, n.d.). This definition underscores the importance of holistic mental health
care in supporting the well-being of Navy personnel and their families.
Investigations by the Department of Defense Inspector General (Inspector General,
2020), Meadows et al. (2018), the Navy Health of the Force (2022), and Russell et al. (2018)
have revealed that the lifestyle and culture within the Navy contribute to the development of BH
disorders among many Sailors. Accordingly, establishing a consistent standard of care for the
identification and treatment of these conditions has become essential. Federal regulations set the
access to care standard for a non-urgent BH assessment at seven days, while the standard for a
specialty mental health referral should not exceed 28 days (IG, 2020). Regrettably, the DoD IG
report found that these standards were not consistently met, with only one of the four naval
hospitals surveyed meeting the 28-day benchmark for specialty BH care (IG, 2020).
In the context of this dissertation, BH providers are defined as psychiatrists,
psychologists, licensed clinical social workers, and psychiatric mental health nurse practitioners.

3
This comprehensive definition aligns with the detailed composition outlined in Cisneros' (2022a)
report to Congress, which underscores the critical role of these professionals within the DoD in
addressing the multifaceted mental health needs of service members and their families. The
demand for BH care in the U.S. military has reached unprecedented levels, with each branch of
the armed services grappling with significant needs for these essential providers. In 2021,
approximately 14% of the active-duty force, translating to around 203,040 service members,
were diagnosed with a mental health disorder (Military Medicine, 2023). Cisneros' (2022a)
report highlighted a stark discrepancy between the number of authorized BH provider positions
and those actually filled, alongside the projected future requirements for these providers, thereby
signifying a substantial shortfall of BH providers across the DoD. This shortage has had
profound implications, including within the Navy, where the insufficient number of BH
providers has severely hampered the ability of Sailors and their families to access timely and
adequate BH care. Consequently, this shortage has significantly impacted overall readiness and
operational effectiveness, necessitating a thorough examination of recruitment and retention
strategies to address the growing need for BH providers (IG, 2020; Donovan, 2020a).
Background of the Problem
The 2018 Health Resources and Services Administration (HRSA) report indicated an
estimated shortage of 9,050 psychiatrists in the United States as of 2016, with projections
increasing to 17,430 by 2030 (HRSA, 2018). The service delivery analysis in the Donovan
(2020a) report identifies projected population growth and provider availability as vital factors
affecting the delivery of adequate care, highlighting the issue of shortages in particular regions.
This scarcity has particularly strained the Navy's efforts to meet the BH needs of Sailors and
their families, affecting critical areas such as access to care, quality of care, and timeliness of

4
care. Consequently, delays in providing BH care jeopardized patient safety and adversely
impacted the readiness of the broader military branches, including naval forces (Donovan,
2020a).
To address personnel shortages, the typical strategy begins with recruitment efforts;
however, the Navy faces numerous challenges in this area. Systemic and budgetary constraints
have been identified as significant inhibitors to effective recruiting within the DoD and the Navy
(Donovan, 2020a; GAO, 2018). These challenges to establishing a robust recruitment program
for BH providers include securing active-duty authorizations, which necessitates obtaining the
necessary approvals to designate specific positions for BH providers within the military's
structural hierarchy. Additional hurdles include dedicated funding and workforce for recruitment,
salary caps, lengthy hiring processes, undesirable remote locations, and overarching national
provider shortages (Cisneros, 2022a; Donovan, 2020a). For both civilian and active-duty BH
providers, competitive pay remains a significant concern, as military branches must compete
with the private and public sectors to attract qualified professionals (Cisneros, 2022a; GAO,
2018).
Within the Navy, the promotion process presents a substantial barrier. Active-duty BH
providers frequently face the risk of being overlooked for promotion, as military culture often
prioritizes leadership roles over clinical ones, consequently leading to retention challenges.
Stewart (2019) noted that several active-duty military psychologists were involuntarily
discharged due to their failure to advance to the next pay grade. For civilian BH providers, the
Navy's hiring process poses significant hurdles, characterized by complex and lengthy
procedures including background checks, licensing verification, and organization-specific
requirements. Cisneros (2022a) reported that at Walter Reed National Military Medical Center,

5
the time required to hire civilians for BH specialties was exceptionally prolonged, resulting in
half of the candidates declining offers during the hiring process. This inefficiency necessitates
restarting recruitment efforts from scratch, further exacerbating the challenges in maintaining a
sufficient workforce.
Organization Context and Mission
Naval Hospital Liberty (NHL) is a pseudonym for a medical treatment facility (MTF)
within Navy Medicine's West Region, which services over 700,000 beneficiaries across 10
hospitals in areas including California, Washington, Hawaii, Guam, and Japan. These facilities
primarily cover the Western Pacific region. NHL’s mission is to provide comprehensive medical
support to various operational Department of the Navy (DoN) units, whether deployed, ashore,
or at sea, and to deliver high-quality health care to Navy retirees, warfighters, and their families.
The Mental Health department at NHL, led by a Navy Captain and board-certified psychiatrist,
serves as the central hub for all BH treatments. It offers a broad spectrum of services such as
outpatient mental health services, a dedicated substance abuse treatment program, an adult
psychiatric unit, and a walk-in mental health clinic. This diverse array of services and the
integration of both military and civilian healthcare professionals make NHL an ideal location for
studying BH issues in the Navy, offering unique insights into varied specialties and the specific
challenges they address.

6
Purpose of the Study and Research Questions
This study aims to investigate the factors contributing to the shortage of BH providers
within the Navy, and to identify potential strategies for expanding BH treatment in the Navy
despite the global shortage of providers. Utilizing Bronfenbrenner's (1979) ecological systems
theory as its theoretical framework, the study examines the complex interactions that influence
BH provider career paths. This theoretical approach allows for a thorough understanding of both
individual and systemic factors affecting BH provider availability in the Navy. The specific
research questions this study seeks to answer are:
1. How does the shortage of behavioral health (BH) providers in the Navy impact
the ability of existing BH providers to meet the needs of current patients and
accept new patients?
2. How do the various levels of the Navy present both obstacles and opportunities
for hiring new BH providers and retaining current BH providers?
3. What strategies can the Navy implement to enhance BH care for Navy
beneficiaries despite the global shortage of BH providers?
Importance of the Study
The growing incidence of BH issues, including suicides and substance abuse among
active-duty Navy Sailors, has been extensively documented in recent studies (Cisneros, 2022a;
NHOF, 2022; Schuler et al., 2022). These reports highlight the critical need to address these
escalating concerns that not only threaten the well-being of naval personnel but also their
operational readiness. Specifically, the NHOF (2022) report disclosed alarming statistics,
revealing that 81 Sailors committed suicide in 2019 alone, underscoring the grave nature of the
crisis. Additionally, the same report noted that from fiscal years 2016 to 2021, Navy Sailors were

7
involved in 6,147 incidents of driving under the influence (DUI), further illustrating the
pervasive challenges related to substance abuse within the naval forces.
These alarming statistics underscore the urgent need to address the challenges
confronting Navy personnel, as the consequences have profound implications for their wellbeing and that of their families. Left unaddressed, these issues may lead to tragic outcomes,
including fatalities and a general deterioration in quality of life. This study seeks to address these
critical concerns by utilizing Bronfenbrenner's (1979) ecological systems theory, which offers a
comprehensive framework for understanding the factors influencing BH provider behavior. By
applying this theory, the research aims to develop effective strategies to alleviate the shortage of
BH providers within the Navy, thus enhancing the overall health infrastructure and support
systems available to naval personnel.
To achieve the goal of understanding and addressing the shortage of BH providers within
the Navy, this study employs a comprehensive methodological approach. This includes a
thorough literature review, qualitative interviews, and detailed data analysis to identify the
factors contributing to this shortage and to develop empirically supported strategies for
expanding BH treatment in the Navy. By examining the experiences and perspectives of BH
providers, the study aims to uncover the systemic and individual challenges that hinder
recruitment and retention efforts. The research also explores the impact of these shortages on the
ability of current BH providers to meet patient needs. Ultimately, the study seeks to contribute to
the knowledge base in the field of BH by proposing effective strategies to mitigate the BH
provider shortage and enhance the provision of critical mental health services to active-duty
Navy personnel and their families, thereby addressing the broader issues of suicides, substance
abuse, and overall welfare among Sailors and their family members.

8
Overview of Theoretical Framework and Methodology
This study aims to examine the shortage of BH providers in the Navy by utilizing
Bronfenbrenner's ecological systems theory (1979) as a theoretical framework. According to
Bronfenbrenner, individual development is a complex system influenced by various levels of the
environment, including family, school, and cultural values. Key concepts from the theory that
will be applied in this study include microsystem, mesosystem, exosystem, macrosystem,
ecological transition, and human development.
To address the research questions effectively, this study utilizes a qualitative narrative
analysis. This method is particularly apt as it enables a comprehensive understanding of the
shortage from the perspectives of BH providers through their personal stories and narratives. As
Merriam and Tisdell (2017) emphasize, narrative analysis provides a powerful means to delve
into the subjective experiences of individuals, offering insights into complex phenomena through
the rich, detailed accounts of participants. This approach is instrumental in capturing the nuanced
dynamics that contribute to the shortage of BH providers, providing a deeper layer of
understanding essential for addressing the issue.
Integrating elements of phenomenology into the study design, this research aims to
uncover the essence of the BH dynamics at NHL (Merriam & Tisdell, 2017). To facilitate a
comprehensive analysis, participants are stratified into two groups, including both uniformed and
civilian psychologists. This focus is chosen because psychologists represent the largest group of
BH providers in the Navy (Hepner et al., 2017). While the study’s geographical scope centers on
NHL, it is important to note that most participants bring diverse experiences from various Navy
BH settings. This ensures that the insights gained reflect a broad spectrum of BH practices and
challenges across the Navy.

9
Definitions
This section identifies definitions used in the study:
• Active-Duty Service Members or ADSMs are used interchangeably in this study
(Donovan, 2020a).
• Behavioral health (BH) is the promotion of mental health, resilience, and well-being; the
treatment of mental and substance use disorders (SAMHSA, n.d.)
• BH provider refers to licensed medical professionals, such as psychiatrists, psychologists,
psychiatric mental health nurse practitioners, and licensed clinical social workers
(Cisneros, 2022a).
• MH disorders are conditions that contribute to distress and problems functioning in
social, work, or family life (IG 2020).
• Military Health System, or MHS refers to the nationalized health care system within the
Department of Defense (DoD) that provides health care to active duty, reservists, and
retired military personnel and their dependents (IG, 2020).
• Military Treatment Facility or MTF is a designated military clinic or hospital (Donovan,
2020a).
• A Network Referral occurs when a beneficiary's primary care manager (PCM) or
healthcare provider directs them to another provider for specialized care that they are
unable to offer (TRICARE, 2022b).
• Paraprofessionals refer to para health professional extenders, a person with education
and training in a specific area of medicine who provides services in that profession as an
extension of an individual licensed to practice independently (Barna, 2018).

10
• Readiness refers to as the ability of the U.S. military forces to fight and meet the demands
of assigned missions (GAO, 2021).
• Shortage refers to having less than 80 % to less than 100 % of authorizations filled
(GAO, 2018).
• TRICARE is the health care program for uniformed service members, retirees, and their
families; TRICARE provides comprehensive coverage to all beneficiaries including
health plans, special programs, prescriptions, and dental plans (TRICARE, 2022b.)
Organization of the Dissertation
In this study, the problem of practice and its relevant contextual information are
thoroughly examined and introduced in Chapter One. A comprehensive review of the literature is
presented in Chapter Two. Chapter Three delves into the qualitative research methodology
employed, providing a detailed examination of the methods used to address the research
questions. Chapter Four critically analyzes the qualitative data collected, describing the
techniques used for data collection, and highlighting the overall objectives of the study. Finally,
Chapter Five offers insightful conclusions and presents well-supported recommendations based
on the findings.

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Chapter Two: Review of the Literature
This chapter provides a comprehensive review of the existing scholarly research on the
shortage of behavioral health (BH) providers in the Navy. The review begins with an overview
of the shortage, including a definition of a Navy BH provider and an exploration of the global
shortage of BH providers. Due to the limited research specifically addressing the shortage of BH
providers within the Navy, this review also incorporates research on the shortage of BH
providers within the broader Department of Defense (DoD) as a proxy. After providing general
background information, the review identifies various factors contributing to the shortage, such
as recruitment, retention, promotion, pay, and complications during the hiring process (Cisneros,
2022a; NHOF, 2022; Stewart, 2019). Building upon this analysis, the review examines common
recommendations found in the literature for addressing the shortage. Bronfenbrenner's (1979)
ecological systems theory is then employed as an analytical framework for understanding the
shortage. This theory posits that understanding human development requires consideration of
different systems of interaction, rather than a single setting, and takes into account the
environment beyond the immediate situation of the subject. As such, the ecological systems
theory serves as an ideal lens for framing the qualitative analysis of this study, as it allows for the
examination of the distinct systems within the Navy and their impact on Navy BH providers. The
following section provides a historical overview of the Navy's BH provider shortage.
Background on the Shortage of Behavioral Health (BH) Providers in the Navy
The shortage of BH providers within the Navy represents a significant obstacle to
ensuring that beneficiaries receive adequate treatment for their mental health conditions. This
issue is not a recent development, as a task force established in 2007 to examine matters related
to mental health and the Armed Forces found that the Military Health System (MHS) lacked the

12
necessary financial resources and personnel to support psychological health in both peacetime
and wartime (Chu, 2007). The MHS is the national healthcare system within the DoD that
provides medical care to active-duty service members, reservists, retirees, and their dependents
(Inspector General, 2020). Despite recommendations to increase funding for psychological
health services for service members and their families (Findings of the Department of Defense
Task Force on Mental Health, 2007) the DoD continues to struggle with a shortage of BH
providers. In 2019, the DoD authorized 5,132 BH provider billets, but only 4,957 were filled,
highlighting a significant gap between the authorized number of providers and the actual number
required to meet the needs of all beneficiaries (Cisneros, 2022a; Donovan, 2020a).
The Department of the Navy (DON) operates under the broader DoD umbrella and
consists of both the United States Navy and the United States Marine Corps (Department of the
Navy, 2010). This structure mandates that the Navy provides medical care, including BH
services, to both Sailors and Marines. Typically, Sailors and Marines do not receive BH care
from the medical departments on their ships or units. Instead, they rely on higher-echelon
medical treatment facilities (MTFs) within driving distance from their duty stations for
comprehensive BH services (Milegan et al., 2020). A duty station refers to the specific location
where a military service member is assigned to live and work; these locations can vary widely
and include naval bases, military installations, and operational sites both domestically and
internationally. Additionally, access to mental health services can be impacted by various
factors, including the availability of providers and the logistical challenges associated with the
duty station's location (Hoge & Paris, 2018; Department of Defense, 2007; Cisneros, 2022a).
The shortage of BH providers has a detrimental impact on patient care, particularly in
terms of access to care. A report by the Inspector General (IG) in 2020 found that none of the

13
four Naval Hospitals inspected met the 28-day threshold for service members and their families
seeking mental health care (IG, 2020). Staffing shortages have consistently emerged as a critical
issue, leading to significant delays in access to care. These delays often result in beneficiaries not
seeing the appropriate provider when needed, missing out on necessary care, or failing to receive
timely follow-up therapy, all of which can jeopardize patient outcomes. The 2020 Inspector
General report highlights these challenges, emphasizing the adverse impact on the quality and
timeliness of mental health services (IG, 2020)
Defining BH Providers in the Navy
Navy BH providers are a critical component of the MHS, responsible for providing
essential BH services to service members and their families. This study defines a Navy BH
provider as a licensed independent provider who is employed by the Navy, including
professionals such as psychiatrists, psychologists, licensed clinical social workers, and
psychiatric mental health nurse practitioners (Cisneros, 2022a). Within the scope of this study,
BH providers are further classified into two distinct categories: therapists and prescribers.
Therapists, typically licensed clinical social workers and psychologists, do not possess the
authority to prescribe medication, while prescribers, such as psychiatrists and psychiatric mental
health nurse practitioners, are authorized to do so (Cisneros, 2022a).
It is important to acknowledge that the term BH providers can encompass various
licensed professionals, such as substance abuse counselors and mental health counselors, in
different contexts. However, for the purposes of this study, the designation BH provider is
specifically limited to psychiatrists, psychologists, licensed clinical social workers, and mental
health nurse practitioners. The subsequent sections of this literature review will provide an indepth examination of the distinctions between active-duty BH providers and civilian BH

14
providers, highlighting the unique challenges and considerations associated with each group.
Overall, the study examining the factors that contribute to the shortage of Navy BH providers is
essential in understanding the complex and critical role they play in ensuring the mental wellbeing of service members and their families.
Uniformed Navy BH Providers
The Navy is a complex organization that comprises a diverse population of personnel,
including enlisted members and officers. Among the officer ranks, there are warrant officers and
commissioned officers (Defense, n.d.). BH providers in the Navy are uniformed commissioned
officers who possess specialized training and expertise as psychiatrists, psychologists, licensed
clinical social workers, and psychiatric mental health nurse practitioners (Cisneros, 2022a;
Donovan, 2020a; Milegan et al. 2020; Stewart, 2019).
As commissioned officers, the highest rank within the military hierarchy, BH providers
serve in a unique capacity, providing care to individuals with whom they serve alongside. They
are also divided among different officer corps based on their specialty, with the Medical Corps
comprising active-duty and reserve physicians, the Medical Service Corps including
psychologists and licensed clinical social workers, and the Nurse Corps comprising nurses from
20 different fields, including psychiatric mental health nurse practitioners (Navy Med, n.d.). In
2019, there were 551 uniformed therapists and 150 prescribers working in MTFs (Cisneros,
2022a; Milegan et al., 2020). It is important to note that these numbers do not reflect BH
providers working outside of MTFs in other capacities such as onboard ships, while deployed, or
within other operational billets.
In addition to the distinction between enlisted and officers, there is also a difference
between active-duty and reserve Sailors. Active-duty Sailors serve full-time, while reserve

15
Sailors are historically used as a part-time defensive protective force (Griffith, 2011); however,
the role of reserve Sailors has expanded over time. Despite this, there are not many differences
found in the literature between the reserve and active-duty Navy BH providers. Reservist
Uniformed BH providers were not employed in the conduct of this research.
The purpose of this study was to analyze the roles and responsibilities of uniformed BH
providers within the Navy, specifically focusing on their activities within MTFs. MTFs are
integral to the MHS, located on military installations worldwide to provide comprehensive
healthcare to military personnel, their families, and other eligible beneficiaries. These facilities
offer a broad spectrum of medical services from primary care to specialized treatments, crucial
for maintaining the health and operational readiness of the military forces (U.S. Department of
Defense, n.d.). Given that a significant portion of the scholarly literature addresses the treatments
and support services these MTFs provide, this study places a particular emphasis on these
aspects. To provide a comprehensive understanding of the topic, the following sub-section will
also delve into the role and contributions of civilian BH providers within the Navy.
Civilian BH Providers
This study utilizes civilian BH providers within the Navy as well. These non-uniformed
individuals, including psychiatrists, psychologists, licensed clinical social workers, and
psychiatric mental health nurse practitioners, work for the Navy as civil service employees
(Cisneros, 2022a). The utilization of civilians in the military is a widespread practice, with the
DOD employing nearly 950,000 civilians in 2020 (DoD, 2021). In addition to their presence in
Navy MTFs, civilian BH providers can also be found working in the U. S. Department of
Veterans Affairs Veterans Affairs (VA) hospitals. The VA health system is the largest integrated
healthcare system in the United States, providing care at 1,298 facilities (VA, 2022). VA

16
hospitals serve active-duty service members (ADSM) in certain circumstances such as
emergency or urgent care. However, for this study, the focus is on civilian BH providers working
exclusively at a Navy MTF.
An essential and distinct category of BH providers within the Navy comprises
contractors. These individuals are neither uniformed BH providers nor civil servants, but rather
employees that provide the government with goods or services under a written contract. They are
frequently utilized to address short-term workload gaps and gaps due to active-duty deployments
or hard-to-fill staffing requirements (Wilkie, 2018). Contractor BH providers are not used in this
study
The Global and National Shortage of BH Providers
The shortage of BH providers is a pressing issue that extends beyond the United States
military, and a comprehensive understanding of the global context of this shortage is essential for
effectively exploring the shortage of providers in the Navy. Studies have consistently
demonstrated that there is a shortage of BH providers worldwide, with increasing demand for
BH treatment (Marengoni et al., 2013; Moitra et al., 2022; Vijay, 2018; Wainberg, 2017;
Whiteford et al., 2013). According to the World Health Organization (WHO, 2022), nearly one
in eight people worldwide live with a mental health disorder, yet access to BH services remain
low globally, particularly in countries with lower socio-economic status (Moitra et al., 2022).
In the United States, this shortage is similarly pressing, with numerous states facing an
inadequate supply of BH providers (Adams et al., 2022; Andrilla et al., 2018; Covino, 2019;
Hoge et al., 2015; Hoge & Paris, 2019; Weigel et al., 2021). A 2018 study funded by the Health
Resources and Services Administration (HRSA) found that 77% of U.S. counties experienced a
severe shortage of prescribers, and nearly one in five counties had an unmet need for therapists

17
(Hoge et al., 2013). This issue is especially acute in rural areas, where Andrilla et al. (2018)
documented that 27% of metropolitan counties lacked a psychiatrist compared to 65% of rural
counties, and 19% of metropolitan counties lacked a psychologist compared to 47% of nonmetropolitan counties.
Regional disparities further exacerbate the issue. The northeastern United States,
including states like Pennsylvania and Massachusetts, generally has a surplus of BH providers in
almost every BH-related field (HRSA, 2018). Conversely, the southeastern United States,
encompassing states such as Texas and Florida, faces pronounced shortages (HRSA, 2018).
These imbalances highlight significant inequities in the distribution of mental health resources
across the country.
This national shortage mirrors challenges faced within the military. According to
Cisneros (2022a), insufficient resources and funding are primary factors contributing to the
global shortage of BH providers. The military, similar to the civilian sector, faces inadequate
staffing to meet the growing demand for BH services. These findings highlight the urgent need
for strategic investment and resource allocation to address the disparities in BH service
availability (Cisneros, 2022a).
Factors that Contribute to the Shortage of BH Providers in the Navy
The literature consistently highlighted several recurring themes regarding the shortage of
BH providers in the Navy. These themes predominantly center around recruitment challenges,
retention difficulties, and compensation issues. Multiple studies emphasized that these factors
collectively contributed to the persistent shortage, impacting the Navy’s ability to maintain an
adequate number of qualified BH providers (Cisneros, 2022a; Donovan, 2020a; Stewart, 2019).
Studies have shown that there is a shortage of BH providers globally, and this issue is also

18
present in the United States, particularly in rural communities. The literature suggests that
resources and funding are major contributing factors to the global shortage of BH providers.
Additionally, specific issues such as recruitment problems, retention challenges, and pay
disparities for Navy BH providers compared to other sectors have been identified as critical
factors contributing to the shortage within the Navy (Cisneros, 2022a; Donovan, 2020a; Stewart,
2019). The hiring process for civilian BH providers in the Navy is notably problematic, often
characterized by lengthy and cumbersome procedures, further exacerbating the shortage
(Stewart, 2019). Understanding these multifaceted factors is essential for effectively addressing
the shortage of BH providers in the Navy and ensuring that service members receive the mental
health care they need.
Recruitment of BH Providers
The recruitment of Navy BH providers, both civilian and active duty, remains a top
priority in addressing the shortage within the Navy (Cisneros, 2022a; Donovan, 2020a; Stewart,
2019). The literature surrounding BH provider recruitment highlights the historical barriers the
Navy encounters when searching for talented BH providers. These challenges include a cap on
annual active-duty authorizations, limited dedicated funding for recruitment, salary caps for both
civilian and military employees, lengthy hiring processes, remote and undesirable locations, and
a global shortage of BH providers (Cisneros, 2022a; Donovan, 2020a; Stewart, 2019).
The shortage of BH providers directly impacts the pool of candidates the Navy can
recruit from, as they are not only competing with other branches of the armed forces, but also
with other federal entities like the VA, local and state governments, as well as private medical
organizations (Cisneros, 2022a; Donovan, 2020a). Government agencies like the VA have more
legal flexibility in terms of structuring civilian pay and comprehensive benefit plans, making it

19
harder for the Navy to compete (Cisneros, 2022a; Stewart, 2019). Compensation is a crucial
recruiting tool for BH providers; however, it remains a significant detractor for Navy
recruitment. Cash compensation BH providers within the Navy is typically lower than their
counterparts in the private sector, even when including cash bonuses (Cisneros, 2022a).The
Navy also offers non-cash incentives in the form of healthcare coverage, tuition reduction
programs, and a pension (Cisneros, 2022a); however, the data show that these are not enough to
entice large numbers of providers to work for the Navy.
A significant obstacle to recruiting BH providers is the lack of awareness regarding DoD
health profession programs and scholarships (GAO, 2019). Cisneros (2022a) found that graduate
medical education and graduate professional education programs are the primary pipelines for
the recruitment of active-duty BH professionals, but scholarships and advertisements for these
programs continue to lag. The military has its own medical school, the Uniformed Services
University of the Health Sciences (USUHS), which is the nation’s federal health professions
academy. Like at the service academies, USUHS students do not pay tuition; they repay the
nation through military service (USUHS, n.d.). Despite the fact that nearly 25% of active-duty
military doctors are USUHS graduates, budget constraints inhibit formal recruiting efforts to
promote program awareness (Donovan, 2020a; USUHS, n.d.). A GAO (2018) study declared
that the retention of physicians accessed through USUHS has historically been greater than that
of physicians accessed through other programs, making it the most cost-effective accession
source for filling senior physician requirements. Collectively, the BH provider shortage,
competition in private and public sectors for talent, and the lack of funding for military health
programs contribute to the shortage of Navy BH providers. As the shortage continues to grow

20
longer and the demand for BH providers grows larger, it only makes it harder for the Navy to
recruit because BH providers will have more leverage and negotiating power.
Recruiting Uniformed Navy BH Providers
Active-duty BH providers constitute the largest segment of the total BH provider
workforce within the Navy. Stewart (2019) details that in 2018, the Navy employed 810 activeduty BH providers, compared to 311 civilian BH providers and 480 civilian contractor BH
providers across all Navy MTFs. This distribution underscores the substantial reliance on activeduty personnel to fulfill the Navy's BH needs. A recent proposal sent to Congress by Cisneros
(2022a) stated that the Navy requires 701 Navy uniformed BH providers, 105 civilians, and 70
contractors specifically to deliver BH care in MTFs. However, the Navy encounters challenges
in expanding the number of BH providers due to force structure limitations imposed by the need
to meet Defense Officer Personnel Management Act (DOPMA) requirements. Cisneros (2022a)
explained that increasing the number of active-duty BH providers led to reductions in other
medical officer career fields, thus limiting the Navy's flexibility to expand overall active-duty
authorizations.
Historically, compensation for Navy BH providers was less than the median
compensation for BH providers in the civilian sector. However, Congress recently authorized
increases for special pay and incentive pay (Cisneros, 2022a). The Navy also offers sign-on
bonuses for BH providers, but these bonuses are subject to staffing and budget levels and have a
cap. According to Med Navy (n.d.-b), for FY 2021, licensed clinical social workers received an
accession bonus of $18,750 for a three-year obligation and $30,000 for a four-year obligation,
while clinical psychologists received accession bonuses of $42,500 and $65,000 for the same
level of commitment. While compensation is a crucial factor in recruitment, other non-

21
compensation factors have also been found to impact the recruitment of active-duty BH
providers.
Serving as a BH provider in the Navy comes with unique challenges. Active-duty Sailors
are bound by their oath to defend the nation, which may require deployment into hazardous
situations. Donovan (2020a) highlights that the frequency and duration of deployments deter
some BH providers from joining the Navy. Furthermore, the demanding lifestyle of a Sailor,
combined with potential financial disadvantages compared to civilian employment, poses
significant obstacles to the recruitment of BH providers in the Navy.
Recruitment Issues for Civilian BH Providers
Recruiting civilian BH providers to work at Navy MTFs involves addressing several
significant challenges, including the protracted hiring process, compensation disparities, and the
requirement to work in less desirable geographical locations (Cisneros, 2022a; Donovan, 2020a;
Stewart, 2019). These challenges are compounded by systemic and budgetary constraints that
hinder effective recruitment within the DoD and the Navy. The Navy's pay structure and benefits
often cannot compete with those offered by the VA or the private sector, making it difficult to
attract qualified professionals (Cisneros, 2022a; GAO, 2018). Additionally, the need to work in
remote or less desirable locations, particularly those outside of the continental United States,
further hampers recruitment efforts for civilian BH providers (Stewart, 2019).
The protracted hiring process significantly impacts the Navy's ability to recruit civilian
BH providers efficiently. Stewart (2019) noted that it can take five to seven months to bring a
civilian on board in the Washington D.C. region. Cisneros (2022a) reported that the average time
to hire a civilian psychiatrist at Walter Reed National Military Medical Center is 546 days, with
similar lengthy hiring times for psychologists and social workers. This delay in hiring is a

22
significant deterrent for potential candidates, who often accept positions elsewhere due to the
prolonged process (Stewart, 2019; Cisneros, 2022a).
Compensation disparities play a crucial role in the recruitment challenges faced by the
Navy. The Navy's pay structures are often less competitive than those offered by the VA or
private sector, making it challenging to attract and retain qualified BH providers (Cisneros, 2022;
GAO, 2021). Although the Navy offers non-cash incentives such as healthcare coverage, tuition
reduction programs, and pensions, these benefits frequently fail to attract a sufficient number of
providers (Donovan, 2020a). Stewart (2019) highlights that the financial packages for civilian
BH providers are particularly inadequate when compared to the higher salaries available in the
private sector and other government agencies, significantly hindering the Navy's recruitment
efforts.
Geographical challenges further complicate the Navy’s recruitment efforts, particularly
for positions in remote areas such as North Carolina and Virginia. Navy MTFs in these less
desirable locations often struggle to attract qualified staff, as the benefits and compensation
packages do not sufficiently offset the disadvantages of working in these regions (Cisneros,
2022a; Stewart, 2019). These remote settings can deter potential candidates due to limited
amenities, professional isolation, and less favorable living conditions compared to urban
environments. Addressing these geographical challenges with innovative solutions is crucial to
enhancing the recruitment and retention of BH providers within the Navy’s healthcare system
(Cisneros, 2022a; Stewart, 2019).
In summary, the recruitment of civilian BH providers for the Navy is a complex process
impeded by factors such as compensation, location, and retention challenges. The prolonged
hiring process further complicates recruitment efforts. Addressing these issues is critical for

23
enhancing the Navy's capacity to attract and retain qualified civilian BH providers, who are vital
to delivering quality care to service members and their families (Cisneros, 2022a; Donovan,
2020a; GAO, 2021; Stewart, 2019).
Retention Shortfalls for BH Providers
The retention of BH providers in the Navy remains a persistent challenge, as highlighted
in numerous reports (Cisneros, 2022a; Donovan, 2020a; Stewart, 2019). Despite ongoing efforts
to address the shortage of BH providers at both legislative and branch-specific levels, the issue
persists and requires a multifaceted approach (Cisneros, 2022a; Stewart, 2019). Addressing these
retention issues is critical for ensuring the continuity and quality of mental health care provided
to Navy personnel.
This section examines the various factors contributing to retention difficulties faced by
both uniformed and civilian BH providers in the Navy. These challenges include promotionrelated issues, compensation disparities, and inefficiencies in the hiring process (Donovan,
2020a; Stewart, 2019). Understanding these factors is essential for developing effective strategies
to enhance the retention of BH providers within the Navy's healthcare system.
contributions.
Uniformed BH Provider Retention Issues
The initial service commitment for Navy officer positions typically ranges from three to
five years, though positions involving extensive training may require longer obligations
(Navy.com, 2024; Naval Officer Recruiter, 2024). One notable example of extended service
commitments is found at USUHS, which was established by Congress in 1972 to train health
professionals for service in the U.S. Armed Forces. Students at USUHS must commit to a
minimum of seven years of service following graduation (USUHS, n.d.). USUHS graduates are

24
trained to work in various medical settings, including BH, through comprehensive programs in
psychiatry, clinical psychology, and nursing (USUHS, 2024). These service commitments, in
conjunction with the challenges of recruiting uniformed BH providers, significantly impact
retention rates. Factors such as competitive compensation and benefits in the private and public
sectors, quality of life considerations, and the overall shortage of BH providers all contribute to
these retention difficulties (Cisneros, 2022a; Donovan, 2020a; Stewart, 2019).
The Navy is aware of the potential risk of losing highly trained and experienced BH
providers at the end of their service commitment and has implemented retention bonuses as a
means of incentivizing uniformed providers to remain on active duty. Eligibility for these
bonuses includes several rigorous requirements, such as maintaining permanent active-duty
status, meeting specific pay grade criteria, accumulating a certain number of years of
commissioned service, maintaining licensure, executing a written agreement to remain on active
duty within a specific specialty, and demonstrating competitiveness for promotion or
continuation in the Navy. (Navy Medicine, 2023). For instance, the Navy offers psychologists up
to a $25,000 retention bonus for a four-year contract and licensed clinical social workers up to
$10,000 for a similar commitment (Navy Medicine, n.d.-b). These financial incentives are
crucial in addressing the retention challenges faced by the Navy in retaining skilled BH
providers.
Retention of uniformed BH providers is not solely a financial decision, as quality-of-life
considerations also play a crucial role. Literature suggests that deployment length and frequency,
time away from family, and assignment to remote or arduous duty stations are factors that may
deter uniformed providers from remaining on active duty (Cisneros, 2022a; Donovan, 2020a;
Stewart, 2019). These stressors are compounded by the overall shortage of BH providers in the

25
Navy, which increases workloads and operational demands on existing personnel, leading to
burnout and dissatisfaction (Stearns & Shoji, 2018). This shortage often makes opportunities in
the private sector or other public sector entities more attractive, as these positions may offer
better work-life balance and competitive compensation (Schuler et al., 2022).
Retention of civilian BH Providers also poses a significant challenge for the Navy, with
similar issues of competition with the private sector and other public sector entities, quality of
life, and the overall shortage of BH providers (Cisneros, 2022a; Stewart, 2019; Schuler et al.,
2022). The Navy is taking proactive measures to address these challenges by increasing retention
bonuses and improving quality-of-life options for civilian providers (Navy Medicine, 2023).
Despite these efforts, the Navy continues to face significant challenges in recruiting and retaining
BH providers, and further research is needed to identify additional solutions to this critical issue.
Civilian Retention Issues
The literature suggests that the Navy is encountering substantial challenges in retaining
civilian BH providers, as an increasing number are leaving their positions. This trend mirrors the
issues faced by uniformed BH providers, with compensation and location emerging as key
factors in retention, as reported by Cisneros (2022a) and Stewart (2019). The national shortage of
BH providers exacerbates this problem, as more lucrative pay and a perceived better quality of
life in the private sector become increasingly attractive to civilian BH providers (Cisneros,
2022a).
In an effort to address these challenges, the Navy has implemented various retention
incentives for civilian BH providers, including retention bonuses, student loan repayment
programs, and relocation incentives (Cisneros, 2022a; Stewart, 2019). However, the
effectiveness of these incentives is difficult to assess, as the Government Accountability Office

26
(GAO, 2020) has found that the DoD and the Defense Health Agency (DHA) do not consistently
collect information on retention bonuses, replacement costs for providers, or competitive private
sector wages. The DHA, operating under the DoD, plays a crucial role in managing health
services for the military, including the administration of retention incentives for civilian BH
providers (DHA, 2024). This lack of comprehensive data hinders the ability to fully evaluate and
refine these strategies for optimal effectiveness.
One of the primary retention incentives for civilian BH providers is the student loan
repayment program, administered by the DHA. This program allows the DHA to repay federally
insured student loans as a means of retaining federal employees, with payments of up to $10,100
annually and a lifetime maximum of $60,000 (DHA, 2017). However, the challenge of filling
positions in rural and remote locations—often considered undesirable by civilians—remains a
significant barrier to retaining civilian BH providers. Even with the availability of relocation
incentives offered by the DHA, these locations continue to pose challenges in retaining civilian
BH providers within the Navy
In conclusion, the Navy faces substantial challenges in recruiting and retaining civilian
BH providers, necessitating further research to identify additional solutions. The Navy’s current
strategy, which includes increasing retention bonuses, expanding student loan repayment
programs, and improving quality of life options for civilian providers, is a step in the right
direction. However, these initiatives must be thoroughly analyzed and evaluated to determine
their effectiveness in addressing the ongoing challenges within this critical area.
challenges.

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Uniformed BH Provider Promotion Issues
Uniformed BH providers in the Navy face significant challenges regarding promotion
opportunities. Stewart (2019) found that leadership roles are prioritized over clinical duties,
which can negatively impact the promotion chances of uniformed providers who are not in
leadership positions. Donovan (2020a) also identified non-clinical workloads, such as
administrative and leadership duties, as contributing factors to attrition and turnover among
uniformed BH providers.
As commissioned officers, who represent the highest ranks within the military hierarchy,
uniformed BH providers possess significant authority and responsibility, surpassing those of
warrant officers and enlisted personnel. Commissioned officers are entrusted with the broad
leadership and management of military operations and personnel, a role that underscores their
strategic importance in military decision-making and operational success (Department of
Defense, 2013). In the United States Navy, officer ranks are categorized into three main groups
based on their responsibilities and leadership roles: junior officers (O-1 to O-3), mid-grade
officers (O-4 to O-6), and senior officers or flag officers (O-7 to O-10) (Cutler et al., 2023).
Despite the Navy offering lucrative retention bonuses, Stewart (2019) found that O-3
psychologists were being involuntarily separated if they were not selected for advancement to O4. The observation indicates a misalignment between the Navy's promotion system and its
retention strategy, particularly as the system fails to adequately recognize the clinical expertise of
BH providers. Stewart (2019) further highlighted that psychologists in operational billets, such as
on ships, are often evaluated against naval officers from unrelated job fields rather than their
peers. This practice results in lower performance evaluations and fewer promotion opportunities
for these specialized providers.

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Impact of Shortage of BH Providers to the Navy
The critical shortage of BH providers within the Navy has far-reaching and complex
repercussions, impacting both individual well-being and the overall operational effectiveness of
the naval force. This section examines the literature on how the shortage of BH providers affects
the Navy as a whole. It then explores the specific impacts on individual service members,
including negative patient outcomes and the increased risk of substance abuse disorders. Finally,
the section addresses the effects on suicide rates. Together, these insights from the literature
inform the potential solutions discussed in the subsequent section.
The Navy's intricate organizational structure is significantly impacted by the shortage of
BH providers at multiple levels. From individual Sailors unable to receive timely BH care, to
entire ships conducting safety stand-downs due to increased suicides, to the Navy Surgeon
General instituting new policies to expand embedded mental health professionals in operational
billets, the shortage of BH providers exerts a profound influence on the Navy (Stewart, 2019).
This pervasive issue disrupts not only the well-being of service members but also the overall
readiness and effectiveness of naval operations.
The literature shows that the area significantly impacted by the shortage of BH providers
is readiness (Cisneros, 2022a; DOD IG, 2020; Stewart, 2019). Readiness is the ability to fight
and meet the demands of assigned missions (GAO, 2021). It can be broken down into individual
readiness and the total force's readiness. Individual medical readiness (IMR) measures a service
member’s compliance with established medical readiness elements, including medical, dental,
and BH status necessary to perform their assigned mission (DoD IMR, 2022).
The DoD’s IMR instruction (2022) categorizes service members into three readiness
levels based on their medical status: Fully Medically Ready (FMR), Partially Medically Ready

29
(PMR), and Not Medically Ready (NMR). Total Force Medical Readiness (TFMR) measures the
percentage of deployable personnel (FMR and PMR) across military branches, aiming for a
minimum of 90% to ensure operational readiness (DoD IMR, 2022). The more service members
who are non-deployable, the lower the TFMR for the Navy. Table 1 provides a summarized
overview of these categories and their definitions.
Table 1
Readiness Categories and Definitions
Term Definition
FMR Fully medically ready: service member is up to date on all medical/dental
requirements and is "deployable" or "deployable with limitations."
PMR
Partially medically ready: service member lacks one or more of the following:
an annual health assessment, immunizations, laboratory studies, or individual
medical equipment like prescription glasses.
NMR Not medically ready: service member is "temporary non-deployable" or
"permanent non-deployable" due to medical reasons.
TFMR Total Force Medical Readiness: the military branch’s specific percentage of
deployable members (FMR and PMR).
Individual readiness has a direct impact on the force’s ability to accomplish assigned
missions. From 2016 through 2020, 456,293 Active-Duty Service Members were diagnosed with
at least one BH disorder, underscoring a critical concern within the military (CRS, 2020). This
data illustrates the significant impact that BH disorders have on military readiness, as
emphasized by Cisneros (2022a). Moreover, mental health conditions accounted for the highest
number of hospital bed days and were the second most common reason for outpatient visits
among service members during this period (CRS, 2020). These statistics highlight the
widespread prevalence of BH disorders and underscore their substantial operational implications
within the military context.

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Access To Care
The shortage of BH providers in the Navy significantly impacts access to care and the
overall well-being of service members and their families. According to a report by the Inspector
General (IG, 2020), this shortage potentially jeopardizes patient safety for thousands of service
members and their dependents. The literature consistently identifies common trends related to
this issue, including breakdowns in access to care (Cisneros, 2022a; Donovan, 2020b; IG, 2020),
declines in the quality of care (Donovan, 2020b), and increased risks of substance use disorders
(SUDs) as documented by Cisneros (2022a).
Timely and appropriate access to care is crucial for effectively managing BH conditions
and promoting overall well-being. The Institute of Modern Medicine (1993) defines access to
health services as the prompt utilization of personal health services to optimize health outcomes
(p. 4). This access plays a pivotal role in combating the stigma associated with BH disorders and
reducing the incidence of unnecessary disability and premature death (Donovan, 2020b). The
Navy provides BH treatment through MTFs, yet beneficiaries frequently report challenges in
accessing care in a timely manner. Federal regulations stipulate that the standard for accessing
BH care should not exceed 28 days from referral (IG, 2020); however, an evaluation by the
Inspector General (IG, 2020) reveals that only one out of four Navy MTFs surveyed meets this
standard.
Moreover, the shortage of BH providers exacerbates issues with access to care beyond
initial referral wait times (Donovan, 2020b). Donovan (2020b) notes a slight decline in access to
care metrics within MTFs, including longer wait times from referral to appointment, extended
wait times from booking to appointment, and prolonged intervals between appointments. Both
the IG (2020) report and Donovan (2020b) attribute these issues to the shortage of BH providers.

31
Collectively, this data indicates that the shortage of BH providers directly impacts access to care,
which has significant consequences for service members, their families, and the overall force
(Cisneros, 2022a; IG, 2020). Additionally, this shortage may also contribute to increased rates of
SUDs among beneficiaries (Cisneros, 2022a).
Substance Use Disorders
The U.S. military frequently exposes service members to stressful, dangerous, traumatic,
and life-threatening events, including not only war, deployments, and combat operations but also
incidents such as sexual assault and other terrifying situations. In 2021, 6,290 service members
reported experiencing sexual assault during their military service, according to Cisneros (2022b).
These traumatic experiences, combined with the general stressors of military life, significantly
elevate the risk of developing mental health conditions and substance use disorders SUDs.
Exposure to traumatic events, such as those experienced in military service, is strongly
associated with the development of SUDs, particularly alcohol use disorder. Studies by the
Department of Defense, RAND Corporation, and other military health experts highlight that the
prevalence of alcohol misuse among military personnel is significantly higher than in the general
population, often as a coping mechanism for dealing with trauma, PTSD, and the pressures of
military life (Bray et al., 2013; Meadows et al., 2018; Schumm & Chard, 2012).The Diagnostic
and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric
Association (APA), defines SUDs as patterns of symptoms resulting from the use of a substance
that an individual continues to use despite experiencing significant problems related to its use
(APA, 2013). These substances include alcohol, caffeine, cannabis, hallucinogens, inhalants,
opioids, sedatives, stimulants, and tobacco. Among these, alcohol is the most prevalently used
substance within the DoD and constitutes the primary cause of SUDs among service members

32
(NHOF, 2022). The 2018 DoD Health-Related Behavior Survey (HRBS) reveals that over onethird of service members reported binge drinking within the past 30 days, with nearly 10%
classified as heavy drinkers (Donovan, 2020c). The DoD Health of the Force report (2022)
further indicates that approximately 2% of female service members and 3% of male service
members would be diagnosed with an alcohol use disorder (AUD), a subset of SUD. Schuler et
al. (2022) also find that the Navy and Marine Corps exhibit the highest prevalence of heavy
episodic drinking (HED), with nearly 40% of surveyed Sailors and nearly 49% of Marines
showing symptoms of a possible AUD.
Despite the ongoing issue of alcohol use within the military, the DoD encounters
challenges in effectively addressing it. The 2022 Inspector General's report to Congress, titled
Audit of Active-Duty Service Member Alcohol Misuse, highlights that military healthcare
providers frequently fail to conduct timely alcohol screenings, resulting in delays in accurately
diagnosing AUDs and providing the appropriate level of care (Stewart, 2019). These delays
negatively impact the physical, social, psychological, familial, and emotional health of service
members, as well as the overall readiness of the military. Additionally, the report identifies that
substance abuse treatment facilities often face understaffing and lack the necessary resources to
adequately treat patients, exacerbating the issue (Stewart, 2019).
A significant reason for the lack of progress in addressing alcohol misuse is the shortage
of BH providers within the Navy. According to Hoge et al. (2015), the shortage of qualified BH
providers in the military setting limits the capacity for timely and effective treatment of SUDs.
Blakely et al. (2021) find that veterans exposed to combat frequently use alcohol as a coping
mechanism, with combat-exposed men more likely to report using alcohol to cope compared to
those without combat experience. However, relying on alcohol in this manner can exacerbate

33
mental health symptoms, creating a cycle of increased drinking and worsening symptoms
(Blakely et al., 2021). Stearns and Shoji (2018) note that the insufficient availability of BH
providers means that service members may not receive proper evaluation and treatment for
SUDs, potentially leading to severe outcomes such as suicide.
Suicide
The issue of suicide within the DoD and the Navy remains a persistent problem, with
rates of suicidal ideation among service members alarmingly high. In 2018, the Health-Related
Behaviors Survey (HRBS) finds that nearly 8% of all service members reported having suicidal
thoughts in the past 12 months, a rate nearly twice as high as that of the civilian population. The
Navy, in particular, exhibits higher rates of suicidal ideation, with 11% of sailors reporting such
thoughts (Meadows et al., 2018). Between 2006 and 2021, a total of 19,378 active-duty service
members (ADSM) died while serving in the armed forces, and a staggering 25% of those deaths
are attributed to suicide (CRS, 2022b).
In an attempt to address this dire situation, the National Defense Authorization Act for
Fiscal Year 2022 includes Section 714, known as the Mandatory Referral for Mental Health
Evaluation (Pub. L. No. 117-81, § 714, 2021). This policy, named the Brandon Act after Navy
Sailor Brandon Caserta who tragically died by suicide in 2018, requires the DoD to establish a
new process that triggers a command-directed mental health evaluation when a service member
discloses a specific phrase to their commanding officer or a supervisor at the rank of E-5 or
above (CRS, 2022). Enlisted ranks in the Navy range from E-1 to E-9, with E-5 being the rank of
Petty Officer Second Class, a non-commissioned officer with significant leadership
responsibilities (Cutler, Hacala, & Kingsbury, 2023). This process also initiates an automatic

34
confidential referral for a BH evaluation, aiming to reduce the stigma around self-reporting and
to protect service members experiencing BH emergencies.
Despite efforts to raise awareness of suicide prevention programs and encourage sailors
to seek treatment, the Navy continues to struggle with suicide rates. In 2020, 66 active-duty
sailors died by suicide, 74 in 2019, and 68 in 2018 (NHOF, 2022). The 2022 Inspector General
(IG) report finds that delays in access to care due to staffing issues remain a significant problem.
The shortage of BH providers not only affects individual sailors but also compromises the
readiness of the entire force. The literature suggests potential solutions to this issue, which will
be discussed in the following section.
Potential Solutions to the Shortage
The literature on the shortage of BH providers within the Navy presents a critical issue
that demands immediate attention. However, it also offers potential solutions to this complex
challenge. This section explores strategies for recruiting and hiring more BH providers, including
the utilization of paraprofessionals, the expanded use of telehealth services, and the engagement
of market providers. By integrating these recommendations, a comprehensive approach can be
developed to effectively address the shortage of BH providers within the Navy. Additionally,
Bronfenbrenner's (1979) ecological systems theory framework will be employed to examine the
influence of Navy system factors on the experiences of Navy BH providers, establishing stronger
connections between these elements.
Holistic Strategies for Improving BH Provider Access
The literature indicates that the shortage of BH providers within the Navy is a
multifaceted issue that cannot be resolved solely through hiring more BH providers or offering
recruitment and retention bonuses. While increasing the number of BH providers is a necessary

35
step, it may not fully address the underlying complexities of the problem (Cisneros, 2022a;
Donovan, 2020a). Research suggests that alternative approaches, such as developing and
utilizing paraprofessionals, expanding telehealth capabilities, and increasing the use of market
providers, could play a crucial role in creating a more comprehensive and effective BH treatment
model for service members and their families (Stewart, 2019; Schuler et al., 2022). These
strategies have the potential to alleviate current shortages by diversifying the means through
which BH services are delivered, ensuring broader access and improved outcomes (Blakely et
al., 2021; Kendall-Tackett, 2019). The subsequent sections will explore these alternative
approaches in detail, assessing their viability and potential impact on the Navy’s BH care system.
BH Providers
The literature on the shortage of BH providers within the Navy suggests that the issue is
multifaceted, requiring a comprehensive approach to address. The Defense Health Board
Taskforce on Mental Health's 2007 report recommends relying more heavily on medical
professionals familiar with military life, as uniformed providers are believed to reduce the stigma
associated with seeking treatment for service members (DHB, 2007). The Navy has since
implemented this recommendation, with the majority of therapists and prescribers in the Navy
now being uniformed providers (Cisneros, 2022a). However, the literature indicates that
challenges such as lucrative incentives in other sectors and a lack of predictable career paths with
opportunities for promotion continue to hinder efforts to recruit and retain uniformed providers
(Cisneros, 2022a; DHB, 2007).
In contrast, the Army adopts a different approach to addressing the shortage of BH
providers, opting to hire more civilian staff than uniformed providers (Cisneros, 2022a). The
Navy also has the option to increase its recruitment efforts for civilian BH providers, as the

36
Defense Health Agency and the Navy are currently working on such initiatives (Cisneros, 2022a;
Donovan, 2020b). Despite these efforts, the need for more BH providers in the Navy remains
pressing. In addition to recruiting more BH providers, the literature suggests the potential
utilization of paraprofessionals as a means of addressing the shortage. The following section will
explore this potential solution and its possible contributions to a more comprehensive and
effective BH treatment model for service members and their families.
Paraprofessionals
The shortage of BH providers within the Navy is a complex issue that requires a
comprehensive solution. One proposed approach involves the increased utilization of
paraprofessionals—individuals with education and training in medicine who provide services
under the supervision of licensed professionals (Barna, 2018). The Navy currently employs two
types of BH paraprofessionals: drug and alcohol counselors and BH technicians (BHTs).
The Defense Health Board Taskforce on Mental Health (DHB, 2007) recommends that
the military services invest heavily in the selection and training of enlisted BH technicians, as
they possess a deep understanding of the military context, hold credibility with fellow enlisted
personnel, and empathize with the stressors their patients face. BH technicians are trained
medical professionals who specialize in the communication methods necessary for assessing and
evaluating service members and their families who require mental health care. Although they are
uniformed paraprofessionals, they are enlisted service members rather than officers. They work
under the supervision of licensed mental health care providers but are not credentialed providers
themselves (RAND, 2019).
Another valuable BH paraprofessional asset in the Navy is the drug and alcohol
counselor. These counselors perform assessments, develop treatment plans, conduct intake

37
interviews, provide group and individual counseling, assist in referral activities, manage
programs, and engage in outreach efforts (Navy Credentialing, 2022). They graduate from Navy
drug and alcohol counselor school and enter a minimum one-year internship as substance abuse
counselor interns. Upon completing their internship, they earn certification as certified Navy
drug and alcohol counselors. After gaining three years of field experience, they can apply for and
take an international certification exam recognized by 40 states, 14 countries, and multiple
federal certification boards (Navy, 2017). Utilizing BHTs and Navy drug and alcohol counselors
can alleviate some of the patient care responsibilities of BH providers. However, the need for
more BH providers in the Navy remains, and further research is necessary to determine the most
effective methods for addressing this shortage.
Telehealth
The persistent shortage of BH providers in rural and underserved areas continues to be a
significant challenge within the healthcare industry. One frequently cited solution in the
literature is the implementation of telehealth services. Telehealth, as defined by the Health
Resources and Services Administration (HRSA), involves the use of electronic information and
telecommunication technologies to support and promote long-distance clinical health care,
patient and professional health-related education, public health, and health administration
(HRSA, 2022). Studies demonstrate that telehealth enhances access to care, reduces costs,
addresses acute and chronic conditions, and enables care delivery in patients' homes and mobile
settings (Weigel et al., 2019; Andrilla et al., 2018).
The utility of telehealth for military populations becomes particularly evident during the
COVID-19 pandemic, which necessitates alternative methods of delivering medical care due to
safety concerns and social distancing measures. Tele-behavioral health emerges as the most

38
widely utilized virtual health service, serving both direct care and civilian network beneficiaries
(GAO, 2022). This transition underscores the potential of telehealth to improve access to mental
health services, especially in remote and rural areas where traditional service delivery is
challenging (Edwards-Stewart et al., 2016).
However, implementing telehealth services for BH treatment presents its own challenges.
The same factors that make telehealth a promising model for rural communities also highlight
difficulties, such as inadequate telephone and internet services in remote areas, which became
particularly evident during the pandemic (GAO, 2022). Despite these challenges, telehealth
remains a viable option for addressing the BH provider shortage. A Navy-wide telehealth plan
requires a synchronized strategy, including a suitable platform for care delivery, necessary
equipment resources, provider support, and comprehensive training for both providers and
patients. Additionally, enterprise-level technical platforms, workflows, support protocols,
recruitment, and training are crucial, along with appropriate regulations and legislation
(Donovan, 2020a; Stewart, 2019b).
Network Referrals
One potential solution to address the shortage of Navy BH providers is to increase the
utilization of network referrals. A network referral occurs when a primary care manager or
provider refers a patient to another provider for specialized care that the initial provider cannot
offer (TRICARE, 2022a). By leveraging network referrals, Navy BH providers can focus on
delivering specialized BH services to active-duty service members and other operational efforts.
In alignment with the National Defense Authorization Act (NDAA) of 2016, the DoD is
restructuring and realigning Military Treatment Facilities (MTFs) to enhance the readiness of
operational and medical forces. A report by Donovan (2020a) identifies 50 MTFs for

39
restructuring and realignment to support the fiscal year 2017 NDAA, with the aim of optimizing
MTF capabilities and redirecting medical resources to address higher-priority readiness and
mission needs. The TRICARE managed care support contractors (MCSCs) are responsible for
maintaining a sufficient network of civilian providers to meet the non-MTF BH care demand for
TRICARE beneficiaries within the required accessibility standards. Each MCSC employs a
proprietary methodology to determine the number of each category of BH providers required to
address the BH needs of TRICARE members in their particular region (Cisneros, 2022a).
This transition is expected to take several years, and the increased demand from
beneficiaries transitioning to local networks is a key driver. However, an Inspector General (IG)
report highlights several issues with care from the network, including timeliness, access to care,
and quality of care (Donovan, 2020b). To improve the effectiveness of network referrals, it is
recommended to increase the use of telehealth capabilities and develop more paraprofessionals.
Additionally, further research is needed to assess the effectiveness of network referrals and to
identify potential barriers to their implementation (Cisneros, 2022a).
In conclusion, addressing the shortage of Navy BH providers requires a multifaceted
approach that incorporates several strategies. Utilizing paraprofessionals, such as substance
abuse counselors and non-licensed BHTs has proven to be an effective solution for increasing the
number of BH providers and improving access to care for active-duty service members
(Donovan, 2020b; Cisneros, 2022). The utilization of telehealth services can also play a crucial
role in delivering BH care to service members in remote locations and increasing the efficiency
of the system (Donovan, 2020b). Additionally, utilizing market providers, such as civilian BH
providers, can effectively address the shortage of BH providers if the quality and access to care
are maintained at the same level as the MTFs (Cisneros, 2022). By implementing these solutions,

40
it is possible to alleviate the shortage of BH providers and improve access to BH care for sailors
and their families.
Bronfenbrenner’s Ecological Systems Theory Model
Bronfenbrenner's (1979) ecological systems theory posits that human development is
shaped by a dynamic interplay of factors within multiple levels of the surrounding environment.
This theory is particularly relevant when examining complex issues such as the shortage of BH
providers in the Navy. According to Bronfenbrenner, development involves "a lasting change in
the way in which a person perceives and deals with their environment" (p. 3). To fully
understand the factors influencing Navy BH providers' decision-making, it is essential to explore
their interactions within various environmental systems, including their immediate surroundings
and broader societal contexts. The relationship between these providers and their environment is
reciprocal, with each influencing and being influenced by the other.
The microsystem, the initial level of the theory, refers to the patterns of activities, roles,
and relationships that the developing child experiences in places where people can readily
engage in meaningful face-to-face interaction (Bronfenbrenner, 1979). Examples of
microsystems include the home, daycare, playground, or school. The interactions within the
microsystem are critical for a child's development as they provide the foundation for the child's
perception of self and the world. The child's immediate family, peers, and teachers all play a
significant role in shaping the child's cognitive and emotional development.
The next level, the mesosystem, encompasses the interrelations among two or more
settings in which the developing child actively participates (Bronfenbrenner, 1979). This system
is essentially a system of microsystems and refers to the connections and interactions between
the different microsystems in a child's life. For example, the relationship between a child's school

41
and family can have a significant impact on their development. If the two systems are working
together, it can have a positive effect, but if they are in conflict, it can have a negative effect.
The exosystem, the third level, incorporates other formal and informal social structures
that do not contain the child but directly influence them by affecting one of the microsystems.
An example of the exosystem would be the parents' network of friends or the policies and laws
that govern the child's school and community. These external systems can have a significant
impact on the child's development, even if the child is not directly involved in them.
The macrosystem, the fourth level, refers to how cultural elements such as norms and
values are imposed by society and experienced by the developing child. This includes the
cultural, economic, and political factors that shape the child's environment. For example, the
culture and values of a community can shape the child's perceptions of gender roles, race, and
social class.
The final level of Bronfenbrenner's (1979) system is the chronosystem. The
chronosystem consists of all the environments that can occur over the life of an individual, such
as major life transitions and historical events, and how they influence the developing child.
These include changes in family structure, economic conditions, and historical events that can
have a significant impact on the child's development.
In conclusion, Bronfenbrenner's (1979) ecological systems theory of human development
offers a thorough and nuanced understanding of the intricacies of child development. The theory
suggests that child development is a multifaceted and dynamic process that is affected by various
levels of the surrounding environment, including the microsystem, mesosystem, exosystem,
macrosystem, and chronosystem. These systems are organized based on their level of impact on
the child and their interactions are bidirectional and characterized by mutuality. By examining

42
the child's immediate surroundings as well as their interactions with the broader environment, it
is possible to comprehend the child's development in the context of this theory. Furthermore, the
theory offers valuable insights for researchers, practitioners, and policymakers working in the
field of child development and BH care. Additionally, considering recent research and studies on
Bronfenbrenner's theory and real-life examples can further enhance our understanding of the
theory and its implications.
Conceptual Framework
Bronfenbrenner's ecological systems theory (1979) offers a comprehensive lens through
which to examine the complex issue of the shortage of BH providers in the Navy. This theory
posits that individuals exist within a network of interrelated systems, each influencing and being
influenced by the others. In the context of this study, the BH provider is situated at the center of
these systems, and their decision-making regarding whether to join, stay, or leave the Navy is
shaped by their interactions with various Navy-related factors.
At the microsystem level, the immediate surroundings of BH providers, including
financial considerations and quality of life for themselves and their families, play a crucial role in
their decision-making. The mesosystem encompasses interactions between various systems, such
as those within a specific MTF or in the geographical area where the BH provider and their
family reside. The exosystem includes larger social structures that can impact BH providers,
such as MTF procedures and policies, issues with promotions, or long hiring times. The
macrosystem refers to broader cultural and societal factors, including the differences between
civilian and military life, and the variability of policies across different MTFs. Additionally, the
macrosystem encompasses the influence of DoD and Navy Medicine policies on retention,
promotion, and bonuses.

43
In conclusion, Bronfenbrenner's ecological systems theory (1979) offers a valuable
framework for understanding the intricate dynamics that influence BH provider retention in the
Navy. By analyzing the impact of multiple interconnected systems—from the microsystem to the
macrosystem—this theoretical perspective sheds light on the various factors that shape BH
providers' decisions to join, remain in, or leave the Navy. Further research employing this
framework could offer critical insights into addressing the ongoing shortage of BH providers
within the Navy's healthcare system.
Ecological Approaches to BH Care Settings
BH providers’ utilization of ecological approaches to understanding the complex
dynamics of BH care settings is a valuable perspective in the field. BH providers exist within a
web of interconnected systems, including microsystems, such as household and professional
relationships, as well as more distal systems, such as professional bodies, local communities, and
broader societal structures (Pickover, 2020). The Navy BH care setting adds unique dimensions
to these systems, with the microsystem potentially including patients who belong to the same
unit as the provider, creating a different type of relationship between patient and provider.
The mesosystem level encompasses the interactions between various systems, such as
those within a specific MTF or in the geographical area where the BH provider and their family
reside. The exosystem level encompasses larger social structures that may impact the BH
provider, such as MTF procedures and policies, issues with promotions within a specific MTF,
or long hiring times. The macrosystem level encompasses cultural and societal factors, such as
the differences between civilian and military life, or the variability of policies across different
MTFs. Additionally, the macrosystem level encompasses the influence of DoD and Navy
Medicine policies on retention, promotion, and bonuses.

44
One example of the application of ecological systems theory in the Navy BH care setting
is the Navy Mobile Care Team which, from 2009 to 2013, provided combat and operational
stress control (COSC) to Navy Sailors deployed to Afghanistan (Campbell & Koffman, 2014).
The MCT's operational model was framed by human ecological systems theory, adapted for
modern combat and warfare landscapes, with a focus on providing care to three different
systems: the individual, the unit, and the organization (Campbell & Koffman, 2014). This
approach highlights the importance of considering not only the individual but also the
surrounding systems and the interactions between them.
In conclusion, ecological approaches to understanding behavioral healthcare settings
offer a valuable perspective for understanding the complex dynamics of BH provider retention in
the Navy and highlight the importance of considering the impact of multiple systems on this
issue. Further research utilizing this theoretical perspective can provide valuable insights for
addressing the shortage of BH providers in the Navy. By examining the interplay between
individual, organizational, and broader systemic factors, such research can inform more effective
strategies for both recruitment and retention.
Ecological Approach to BH Programs
The utilization of ecological approaches to understanding the complex dynamics of BH
settings is a valuable perspective in the field, as highlighted by various scholars in the field such
as Pickover (2020), Bunch (2016), and Bronfenbrenner (1979). Health, as defined by the World
Health Organization (1948), is a state of complete physical, mental, and social well-being. From
an ecological perspective, health outcomes develop from interrelationships within coupled
human and natural systems. The social and environmental context plays a crucial role in the
development of BH, as it does for physical and mental health.

45
Person-centered care, which is respectful and responsive to individual patient
preferences, needs, and values (Institute of Medicine, 2001), is a key aspect of ecological
approaches to BH care. Studies have shown the effectiveness of person-centered care in
improving treatment outcomes for patients with BH disorders. For example, Kimerling et al.
(2015) found that treatment for depression, pain management, coping with chronic general
medical conditions, sleep problems, weight management, and posttraumatic stress disorder
(PTSD) emerged as the important priorities for female veterans receiving patient-centered mental
health care through the VA health system.
Bronfenbrenner's (1979) ecological systems theory is particularly relevant in the field of
BH care. The patient in BH treatment is at the center, and the environments and systems around
them, and their interaction with these environments, shape their experiences and the outcomes of
their treatment. The microsystem, mesosystem, exosystem, and macrosystem, as described by
Bronfenbrenner (1979), are all important in understanding the complex dynamics of BH care and
how different systems can impact the patient's experiences and outcomes. In conclusion, an
ecological approach to understanding BH care settings offers valuable insights into the complex
dynamics of BH care. Person-centered care and Bronfenbrenner's ecological systems theory
development are key concepts in this approach, providing a holistic understanding of how
different systems and environments impact the patient's experiences and treatment outcomes.
Microsystem and Mesosystem Context
The microsystem and mesosystem, as posited by Bronfenbrenner's ecological systems
theory (1979), play a crucial role in shaping an individual's development and decision-making. In
the context of adult Navy BH providers, the microsystem encompasses a wide range of
interactions and relationships, including those with family members, friends, colleagues,

46
patients, and the chain of command. These interactions within the microsystem can have a
significant impact on the BH provider's decision to join, remain, or leave the Navy, as the people
closest to them in the microsystem can play a pivotal role in their decision-making process. For
example, a newlywed or new parent BH provider may not find the Navy to be an ideal employer
due to the potential for deployments and prolonged periods of separation from family, aligning
with Bronfenbrenner's observation that interactions within the microsystem significantly impact
individuals' decisions and adaptations (Bronfenbrenner, 1979).
The mesosystem, which is defined by Bronfenbrenner (1979), refers to the
interrelationships between two or more settings where the individual actively participates. For
example, this can be seen in a Navy BH provider s relocation to a new duty station with their
family, or in the interactions between colleagues who attend the same church. These interactions
that occur within the mesosystem can also shape a BH provider's decision-making process. For
example, a BH provider may base their decision to stay or leave the Navy on their experience at
a specific Military Treatment Facility (MTF), without considering the possibilities offered by
other MTFs.
It is important to note that the microsystem and mesosystem are not mutually exclusive
and can interact with each other (Bronfenbrenner, 1979). The experiences and interactions within
the microsystem can also influence the BH provider’s decision-making within the mesosystem
and vice versa. In conclusion, an ecological approach to understanding BH care settings offers
valuable insights into the complex dynamics of BH care. Person-centered care and
Bronfenbrenner's theory of ecological development are key concepts in this approach, providing
a holistic understanding of how different systems and environments impact the patient's
experiences and treatment outcomes. In the context of adult Navy BH Providers, the

47
microsystem and mesosystem play a crucial role in shaping an individual's decision-making
process and development.
Exosystem
The exosystem, a concept within Bronfenbrenner’s ecological systems theory of human
development (1979), can influence the career decisions of adult Navy BH providers. It refers to
the external environment that shapes an individual's behavior and decision-making, even when
they have no direct contact with it. For BH providers in the Navy, external policies and
regulations significantly affect their perception of career development prospects, professional
growth opportunities, and overall job satisfaction.
External policies and regulations play a critical role in shaping the perception of BH
providers regarding career development prospects, opportunities for professional growth, and
overall job satisfaction. The announcement of a proposed policy offering uniformed
psychologists an annual salary of $200,000 to retain their services is an example of how the
exosystem may impact the decision-making of BH providers to stay or leave active duty.
Additionally, the potential revocation of retention bonuses for uniformed BH providers may also
have an influence on their decision. It is essential to understand the impact of external policies
and regulations beyond financial considerations to develop effective strategies that can retain
highly qualified BH providers and improve the overall quality of BH care in the Navy. Other
examples of how the exosystem can impact BH providers' decision-making include lengthy
hiring processes, lack of promotions for psychologists, and the closure of certain Military
Treatment Facilities (MTFs) by the Navy. All these factors can have a profound impact on BH
providers' perception of their career development prospects and opportunities for professional
growth.

48
To address the shortage of BH providers and improve the overall quality of BH care in
the Navy, it is crucial for Navy and Defense Health Agency (DHA) leaders to understand the
exosystem's role in shaping BH providers' decision-making and develop effective strategies
accordingly. This can include examining and addressing issues related to financial compensation,
promotion opportunities, hiring processes, and facility closures. By addressing these external
factors, the Navy can better retain highly qualified BH providers and improve the overall quality
of BH care for active-duty Navy Sailors and their families.
Macrosystem Influences
BH providers play a crucial role in ensuring the mental well-being of individuals within
the military. However, their behavior and decision-making are not solely determined by their
professional training but also shaped by the cultural norms and societal factors of the
macrosystem, as posited by Bronfenbrenner’s ecological systems theory (1979). The
macrosystem encompasses influences such as a deep sense of duty or gratitude towards serving
one's country, the culture of the military organization for uniformed BH providers, the culture
within the military organization for civilian BH providers, or the culture of the BH provider
profession. Additionally, more abstract influences like ethnicity, regional values, and economic
status also play a role in shaping the interactions between various systems (Campbell &
Koffman, 2014). This present study aimed to explore the complex web of cultural and societal
influences that shape the experiences and outcomes of BH providers by utilizing the
macrosystem as a theoretical framework.
This study has shown that the macrosystem plays a significant role in shaping the
behavior and decision-making of BH providers. By understanding the impact of cultural norms,
societal factors, and other macrosystemic influences on BH providers, we can gain insight into

49
the factors that shape their behavior and decision-making. This knowledge can be used to inform
strategies to retain and support highly qualified BH providers and improve the overall quality of
BH care in the Navy. It is crucial to continue exploring the macrosystem as it relates to BH
providers to better understand and support their important work. Figure 1 applies
Bronfenbrenner's (1979) ecological systems theory to analyze the experiences of Navy BH
providers during the current shortage.
Figure 1
Conceptual Framework
Note. Adapted from the ecology of human development: Experiments by nature and design, by U
Bronfenbrenner, 1979, Harvard University Press.
Conclusion
In conclusion, this literature review provides a comprehensive examination of the
shortage of BH providers in the Navy. The literature examines various factors contributing to the

50
shortage, such as recruitment, retention, promotion, pay, and complications during the hiring
process (Cisneros, 2022a; Donovan, 2020b; NHOF, 2022; Stewart, 2019). Furthermore, the
literature examines common recommendations for addressing the shortage.
Using Bronfenbrenner's (1979) ecological systems theory as an analytical framework,
this literature review provides a nuanced exploration of the intricate relationships between BH
providers and the broader United States Navy system. The shortage of BH providers in the Navy
has a detrimental impact on patient care, particularly in terms of accessibility to critical services
(Chu, 2007; Cisneros, 2022a; DoD Task Force, 2007; IG, 2020; Milegan et al., 2020; Stewart,
2019), underscoring the urgent need for further research and understanding of the issue at hand.
Ultimately, this literature review presents a comprehensive understanding of the complexities
surrounding the shortage of BH providers within the Navy, serving as a valuable resource for
future scholarship and study.

51
Chapter Three: Methodology
The purpose of this study was to explore perspectives of behavioral health (BH)
providers who work for the Navy on the factors contributing to the shortage of BH providers
within the Navy. Additionally, due to the global shortage of providers, this study also explored
options to increase BH treatment in the Navy without hiring more providers. Bronfenbrenner's
(1979) ecological systems theory was the theoretical framework selected to explore the
multifactorial interactions that shape BH professionals' career paths. To understand the shortage
of BH providers in the Navy, this study explored the following research questions:
1. How does the shortage of behavioral health (BH) providers in the Navy impact the
ability of existing BH providers to meet the needs of current patients and accept new
patients?
2. How do the various levels of the Navy present both obstacles and opportunities for
hiring new BH providers and retaining current BH providers?
3. What strategies can the Navy implement to enhance BH care for Navy beneficiaries
despite the global shortage of BH providers?
Overview of Methodology
The objective of this research was to utilize qualitative interview methods with Navy BH
providers to gain a deeper understanding of their perceptions and experiences regarding the
current shortage of BH providers in the Navy. The investigation aimed to address the three
research questions and elicit additional insights into the practical problem at hand. Rather than
attempting to establish causality or correlation between the shortage of BH providers and other
factors, the study centered on comprehending the phenomenon from the BH providers'
perspective. According to Merriam and Tisdell (2016), while quantitative research aims to

52
predict, control, describe, confirm, and test hypotheses, qualitative research aims to explore,
discover, interpret, and generate new understanding, thus providing an in-depth understanding of
the research topic. The goal of this study was to contribute to the existing knowledge of the
shortage of BH providers in the Navy by providing a comprehensive understanding of the
phenomenon from the BH providers’ perspective.
The Researcher
As a researcher and administrator within the NHL Directorate for Mental Health, it was
important to acknowledge the complexities and nuances of my positionality, power dynamics,
assumptions, biases, and identity in relation to the study at hand. At the time the research began,
I was an active-duty Navy Hospital Corpsman, situated within the mental health department at
NHL, but my role as a researcher in this study placed me in the position of an outsider. Although
I interact with many of the participants in the study as part of my work within the BH field, it is
crucial to note that I am not a provider, but rather an administrator. In this sense, I held no
positional authority over any of the subjects in the study, nor did I exert any influence over the
respondents.
In terms of power dynamics, it is important to note that all the participants in the study
held an advantage over me in relation to their positions within the organization as providers.
They were paid more than me and held higher rank, whether civilian or uniformed staff. The one
area where I might exert an increased level of power over the BH providers in the organization is
through my relationship with the senior leaders within the department. As the sole healthcare
administrator within the department, I engaged in daily meetings with leadership and provided
recommendations on administrative matters. However, it is important to acknowledge that this
direct access to leadership might elicit apprehension among the interviewees that their answers

53
could be shared with leadership. As such, it was incumbent upon me to mitigate these concerns
and ensure the confidentiality and anonymity of the participants.
As highlighted by Merriam and Tisdell (2016), there is often a level of mistrust and
skepticism from marginalized groups toward researchers from dominant cultures studying
oppressed groups. However, in this case, the focus was on a more elite and sophisticated
population within the Navy. To mitigate any potential issues related to this, a method of
deference to the participants' knowledge and expertise was employed throughout the research
process.
Data Source: Interviews
This research study employed a single methodology for data collection, which involved
conducting qualitative interviews. Although this method was more time-consuming than surveys,
the data collected from these interviews were anticipated to be highly descriptive and
informative, capturing the personal experiences and stories of the participants. As described by
Merriam and Tisdell (2016), qualitative research often relies on various forms of data such as
quotes, notes, and recordings of the interviews to augment the descriptive nature of the research.
The type of interviews conducted were structured or standardized interviews, in which
the precise wording and order of the questions were predetermined, and all respondents were
asked the same questions (Johnson, 2014; Merriam & Tisdell, 2016). This approach simplified
data comparability, as all respondents answered the same questions. The interviews were
conducted both face-to-face and online, depending on the participants' preferences.
In conclusion, this study employed a qualitative methodology that utilized structured
interviews to capture the personal experiences and stories of the participants. The data collected
through this method was expected to provide rich and descriptive insights into the experiences of

54
uniformed and civilian BH providers within the United States Navy. The next section will detail
the process of participant selection and recruitment.
Participants
The aim of this study was to interview 12 participants, with the sampling size adjusted if
saturation was reached before obtaining 15 interviews. According to Merriam and Tisdell (2016),
saturation occurs when data gathering no longer provides new information or insight. The sample
size could exceed 15 if the collected data remained divergent across all participants as the
interviews progressed. The data collection process was conducted alongside data analysis as it
was impossible to predetermine when redundancy or data saturation would occur.
Participants in this study consisted of 12 psychologists, including six uniformed and six
civilian BH providers, currently working at NHL, the study site. The selection of participants
was purposeful, with the researcher choosing participants who could provide the most
information, insight, and understanding about the research topic. This approach allowed for a
deeper understanding of the subject matter being studied. Two criteria were used for the
selection of participants for this study:
• Criterion 1: The participants must be Navy Psychologists who are either uniformed or
civilian staff. Although other healthcare personnel or administrative hospital staff
may be able to provide insight into this study, the goal is to gain perspective based on
personal experiences from actual BH providers.
• Criterion 2: The participants had to work at NHL. Although the issue of BH provider
shortages is experienced Navy-wide, it was preferable for the participants to be within
a reasonable distance from the researcher for logistical reasons. If the number of

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participants within the region had fallen short of the target, the search would have
been extended to the nearest Naval Hospital to achieve the required sample size.
Psychologists were specifically chosen for this study because they represented the largest
group of BH providers at NHL, and psychologists constitute the largest percentage of BH
providers within the Navy overall (Stewart, 2019). This strategic selection ensured that the study
captured a representative sample of the primary BH provider workforce in the Navy, providing a
robust basis for understanding the broader implications of the BH provider shortage. The
selection of participants from both uniformed and civilian backgrounds aimed to provide a
comprehensive perspective on the issue, encompassing a wide range of experiences and insights.
This approach was intended to ensure that the findings of the study were both rigorous and
reflective of the diverse realities faced by Navy BH providers.
Instrumentation
This study employed a qualitative methodology, utilizing semi-structured interviews as
the primary data collection method. I developed the interview protocol, consisting of 15 openended questions, based on a comprehensive literature review. The questions were designed to
elicit rich and descriptive responses from the participants and were structured in a way that
progressed from introductory-type questions to those that specifically addressed the research
questions. The participants were asked to reflect on the shortage of BH providers in the Navy
and its impact on their personal experiences. Additionally, the interview protocol included a
section for discussing potential solutions to the shortage. Finally, the interview concluded with
an opportunity for the participants to raise any additional ideas or topics they wished to explore.
The interview protocol can be found in Appendix A.

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I followed the four major categories of questions from Strauss et al. (1981): hypothetical
questions, devil’s advocate questions, ideal position questions, and interpretive questions. Using
hypothetical questions allowed the respondent to provide details about their own experiences
under the guise of sharing a hypothetical scenario. Devil’s advocate questions depersonalized the
issue and were ideal for controversial subjects (Merriam & Tisdell, 2016). Ideal position
questions revealed both positives and negatives by discussing the interviewee’s views on an ideal
situation. Finally, interpretive questions provided a check on my understanding from the
interview and helped solicit more information, opinion, and feelings from the BH providers.
The interview protocol for this study was structured but also allowed for opportunities for
follow-up questions or probes. As Merriam and Tisdell (2016) explained, these unwritten and
unplanned probes were effective in eliciting more in-depth responses from the participants. The
interview questions were designed to address all the research questions in the study, with each
research question having multiple corresponding questions in the interview protocol. With the
implementation of these techniques, the data obtained from the interviews were expected to be
rich and descriptive. Therefore, the use of structured interviews with opportunities for follow-up
questions or probes proved to be an effective method for collecting comprehensive qualitative
data.
Data Collection Procedures
The recruitment process of participants was a crucial step in this study. To ensure
eligibility, participants had to be psychologists, either civilian or uniformed staff, and must be
currently working at NHL. I recruited participants by sending email solicitations that included a
brief message and a flyer highlighting the goals, inclusion criteria, and expectations for
participation in the study (as detailed in Appendix B). Participants could express their

57
willingness to participate by responding through email, phone call, or text. After confirming their
participation, I provided participants with the Information Sheet for Exempt Studies (Appendix
B) to obtain informed consent. I arranged a convenient time and location for the interview with
each participant, who did not receive compensation for their participation.
The interviews were conducted in a setting that was most conducive to the comfort and
ease of the participants. To accommodate the preferences of the respondents, a variety of
meeting locations and media were utilized, including in-person, online platforms such as
Microsoft Teams, and over the phone. The duration of the interviews was ideally 60 minutes,
with the option for respondents to request a shorter or longer interview time if necessary. It was
important to note that all interviews were recorded, either through audio or video recording, with
the understanding that participants had the right to decline recording if they so chose. If
recording was not possible, written notes were taken during the interview with the prior consent
of the participant, as per the guidelines outlined by Merriam and Tisdell (2016).
Data Analysis
The extensive interview data were analyzed through a technique known as qualitative
content analysis. As articulated by Krippendorff (2013), this method entailed a systematic
examination of texts of various forms, taking into account both the themes and main ideas
present, as well as their manifest content. Unlike quantitative methods, qualitative content
analysis did not rely on statistical techniques; rather, it aimed to identify patterns, instances, and
themes within the data collected from the interviews. As stated by Merriam and Tisdell (2016),
the ultimate objective of data analysis was to uncover answers to the research questions, which
could manifest as categories, themes, or findings.

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Data analysis is a complex process that requires careful attention to detail and a
systematic approach. Merriam and Tisdell (2016) outline a six-step process for conducting data
analysis in qualitative research:
1. Focus on the purpose of the study.
2. Think about the lens of the epistemological framework-in this case, the ecological
systems theory.
3. Code the data.
4. Identify main themes that emerged.
5. Identify if the individual data bits support what is thought about the main theme.
6. Combine the codes into fewer, more comprehensive categories.
The data analysis process played a crucial role in the success of any research study, and it
was essential to choose an appropriate data analysis method to ensure accurate and reliable
results. For this study, the six-step data analysis process proposed by Merriam and Tisdell (2016)
was followed to ensure that the data collected from the qualitative interviews were accurately
analyzed. This process involved a careful consideration of the purpose of the study, the
epistemological framework of the ecological systems theory, the coding of the data,
identification of the main themes, and determining whether the individual data bits supported the
main theme. Lastly, the codes were combined into fewer, more comprehensive categories.
In addition to the six-step data analysis process, the use of the ATLAS.ti software was
also employed for data analysis. The ATLAS.ti software provided several benefits for qualitative
research, including the ability to locate, code, and annotate findings in both text-based and
multimedia data (USC, IT, 2017). The software also provided a feature that allowed for the
visualization of complex relationships between data, which could help to identify patterns and

59
trends that might not be easily recognizable through a simple reading of the data. By utilizing the
ATLAS.ti software, this study aimed to enhance the accuracy and reliability of the data analysis
process, which could provide valuable insights into the experiences of BH providers in the Navy.
Credibility and Trustworthiness
Credibility in research referred to the level of trust and confidence that could be placed in
the findings of a study (Merriam & Tisdell, 2016). It was a measure of the internal validity of the
research and was concerned with the degree to which the findings accurately reflected the truth
of the phenomenon being studied (Lincoln & Guba, 1985). To establish credibility in this study,
several strategies were employed, including prolonged engagement with the research subject,
persistent observation, and triangulation. Prolonged engagement referred to the amount of time
spent conducting the research, which increased the researcher's understanding of the subject
matter and allowed for more accurate and in-depth findings. Persistent observation referred to the
continued and consistent observation of the research subject, which provided a more
comprehensive understanding of the phenomenon being studied. Triangulation referred to the use
of multiple methods and data sources to validate the findings of the study, ensuring the accuracy
and reliability of the results.
As explained by Korstjens and Moser (2018), prolonged engagement was investing
enough time to become familiar with the setting and context, to test for misinformation, to build
trust, and to get to know the data. I had worked within the mental health directorate at NHL for
over 3 years and during that time, I had been able to build relationships with most of the BH
providers that I canvassed. I also had the unique opportunity to witness first-hand some of the
examples that were discussed in the literature review on the shortage of BH providers in the
Navy (Lincoln & Guba, 1985). This prolonged engagement ensured that the research findings

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were credible and trustworthy, as it allowed for a better understanding of the context and setting
of the study.
As outlined by Lincoln and Guba (1985), persistent observation involved identifying the
key elements and features relevant to the research topic and focusing in-depth on them. In this
study, I strove to gain insight from experts in the field and the interviewees and considered their
perspectives on the subject at hand. I made a deliberate effort to avoid allowing personal biases
or pre-existing assumptions to influence the research and did not solely rely on the literature
review as a guiding principle. Instead, I was attentive to any recurrent themes that arose during
the interviews and actively sought to further explore those topics.
In this study, triangulation was employed as a strategy to increase the credibility and
validity of the research findings. According to Merriam and Tisdell (2016), triangulation
involved collecting and analyzing data from multiple sources, using multiple methods, and/or
from multiple perspectives. This was achieved by interviewing a diverse group of psychologists
from different specializations and backgrounds, including uniformed members and civilians, at
the same location, NHL. This approach of comparing and cross-checking data obtained through
observations at multiple times or locations, or interview data collected from individuals with
different views, allowed for the identification of patterns and themes that might be missed by
relying on a single source or method of data collection. Overall, triangulation provided a more
comprehensive and holistic understanding of the research topic and increased the trustworthiness
of the findings.
Member checks, also known as respondent validation (Merriam and Tisdell, 2016),
involved returning data, analytical categories, interpretations, and findings to the members of the
groups from which the data were gathered. Member checks were necessary particularly because

61
the researcher and respondents viewed the data through distinct lenses (Korstjens and Moser,
2018). This was an important step to ensure that data had not been misinterpreted and for me to
be able to check my own biases during the study. Due to time constraints, member checks were
not used in this study. There was not enough time for members to provide me with feedback and
for that feedback to be implemented into the study. Instead, participants had an opportunity to
review the transcripts.
The rigor and trustworthiness of a qualitative study could be evaluated by assessing the
confidence of the researcher in the data, interpretation, and methods used to ensure the quality of
the study (Polit & Beck, 2014). Another important aspect in determining trustworthiness was
authenticity, which, as Connelly (2016) noted, was a unique feature of qualitative research that
allowed for a deeper understanding of the phenomenon being studied. Through interviewing BH
providers working at a Naval Hospital, I could authentically explore their experiences, providing
a comprehensive understanding of the topic. In conclusion, utilizing both trustworthiness and
authenticity as evaluation criteria greatly enhanced the credibility of this study.
Ethics
This This study utilized qualitative research methods to collect data from individuals who
had direct experience in the field of investigation. The research design aimed to maintain a
balance between extracting valuable insights and reducing any potential harm to the participants
(Maxwell, 2013). The primary objective of this study was to prioritize the safety and well-being
of all volunteers involved. Qualitative methods were utilized to acquire a holistic comprehension
of the problem at hand, specifically the shortage of BH providers in the Navy. Additionally, the
study aimed to examine the ramifications of this shortage, as well as to explore potential
solutions to address this issue. The results of this research were significant in providing a deeper

62
understanding of the complexities surrounding the scarcity of BH providers in the Navy and
contributed to the development of effective strategies to address this problem.
In this study, the interview process could elicit psychological stress in participants,
potentially stemming from reliving past experiences or the fear of negatively depicting the Navy.
As such, the protection of the well-being and autonomy of the participants was of paramount
importance. Measures were taken to foster an environment in which participants felt comfortable
sharing their experiences while maintaining a level of confidentiality to safeguard their personal
information and privacy.
The proposed research underwent a thorough review by the Institutional Review Board
(IRB) at the University of Southern California to ensure compliance with ethical standards and
guidelines. The IRB had the authority to approve, request adjustments, or reject the study based
on its adherence to these standards. Upon receiving clearance, data collection commenced in
accordance with the approved study design, with the ultimate goal of achieving the objectives of
the research while maintaining the safety and well-being of the participants. I believed that the
study design was carefully crafted to meet the requirements outlined by the IRB.
To ensure the comfort and security of the participants, a comprehensive pre-interview
discussion was conducted following the guidelines established by Taylor and Bogdan (1984).
The discussion covered the focus of the research, the problem of practice, the study's objectives,
as well as the confidentiality and anonymity measures that were implemented to ensure the
protection of participants. To maintain the anonymity of the participants and the research
location, pseudonyms were employed. The researcher emphasized that participants had the
freedom to withdraw from the interview process at any point without any negative consequences.

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The pre-interview phase also covered the logistics of the interview process, as well as any
follow-up interviews that might be required.
The management of collected data for this study strictly adhered to federal research
practice regulations. Patient confidentiality and privacy protection guidelines stated in the Health
Insurance Portability and Accountability Act of 1996 (HIPAA) were closely followed, even
though the study did not involve actual patients. All digital recordings of interviews were
securely stored on a password-protected personal computer. Identifying information such as
names and ages were removed from transcripts and digital copies. The transcription of
handwritten notes was also done on the computer, ensuring that all confidential information was
kept private. To ensure that all study participants remained anonymous, all transcripts and
records were securely deleted upon the publication of the final report.

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Chapter 4: Findings
The purpose of this qualitative inquiry was to investigate the factors contributing to the
shortage of behavioral health (BH) providers within the Navy and to identify potential strategies
for expanding BH treatment in the Navy despite the global shortage of providers. The problem of
practice is the significant shortage of BH providers in the Navy, which negatively impacts the
mental health and well-being of Navy Sailors and their families by limiting their access to
adequate and timely BH treatment. The following research questions were developed to guide
the study:
1. How does the shortage of behavioral health (BH) providers in the Navy impact
the ability of existing BH providers to meet the needs of current patients and
accept new patients?
2. How do the various levels of the Navy present both obstacles and opportunities
for hiring new BH providers and retaining current BH providers?
3. What strategies can the Navy implement to enhance BH care for Navy
beneficiaries despite the global shortage of BH providers?
This chapter aimed to present the study's findings in a structured manner, organized
around the research questions. Each major section of this chapter detailed the findings that
answered these questions. The chapter included themes that emerged during data analysis,
supported by data and narratives from the participants to highlight key points and insights. This
chapter addressed the research questions by presenting the key themes identified from interviews
with BH providers at Naval Hospital Liberty (NHL). Each theme was explored through direct
quotes from participants, followed by summaries that contextualized these findings within the
broader study framework.

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Themes were determined based on the recurrence and significance of specific issues
highlighted during the interviews. Rather than relying on a fixed percentage of participants,
themes were identified through a combination of frequency and the depth of discussion around
particular topics. For example, if an issue was brought up multiple times across different
interviews and was discussed in detail, it was elevated to the level of a theme. Additionally, the
context and intensity of the responses were considered. If a particular problem elicited strong
emotions or was repeatedly linked to critical challenges, it was deemed significant. This
approach ensured that the themes were both representative and reflective of the core issues
affecting BH providers. The themes were presented sequentially to address each research
question, allowing for a clear and structured discussion of the findings. This organization
ensured that the analysis was systematic and logical, facilitating a comprehensive understanding
of the impact of BH provider shortages on patient care and the operational challenges within the
Navy's healthcare system. By structuring the chapter in this way, the study provided a coherent
narrative that linked the research questions with the thematic findings, ensuring thorough
exploration and clear articulation of each theme.
Participants
This study included 12 psychologists from NHL, comprising an equal mix of six
uniformed and six civilian providers. The participants represented various racial backgrounds,
including White, Black, Hispanic, and Middle Eastern, reflecting the diversity within the Navy's
healthcare workforce. Among the participants, there was an equal distribution of staff-level
providers and supervisors, offering a balanced view of the BH challenges and administrative
issues within the Navy. Civilian participants were designated as C1-C6 and uniformed personnel
as N1-N6, ensuring anonymity while facilitating clear reference throughout the study. The group

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consisted of four males and eight females, highlighting a gender distribution that allows for
diverse insights into the BH challenges faced by the Navy. This diversity in background,
professional status, and roles provided a comprehensive cross-section of experiences for
analysis, enriching the study's findings. Table 2 presents the detailed demographic characteristics
of the study participants. Pseudonyms have been assigned to each participant, as indicated in the
table, and these pseudonyms will be consistently used throughout the discussion of the findings
in this chapter. This approach ensures clarity and confidentiality, allowing for an in-depth
exploration of the themes and patterns that emerged from the data.
Table 2
Demographic Information of Participants
Pseudonym Status Position level Gender
C1 Civilian Staff Male
C2 Civilian Staff Female
C3 Civilian Staff Female
C4 Civilian Supervisor Male
C5 Civilian Staff Male
C6 Civilian Supervisor Female
N1 Active-Duty Supervisor Female
N2 Active-Duty Supervisor Female
N3 Active-Duty Staff Female
N4 Active-Duty Supervisor Male
N5 Active-Duty Staff Female
N6 Active-Duty Supervisor Female

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Research Question 1: How Does the Navy’s Shortage of BH Providers Impact Existing BH
Providers’ Capacity to Meet the Needs of Their Existing Patients and to Accept New
Patients?
Addressing the first research question was crucial as it delved into the immediate and
practical implications of the BH provider shortage on the frontline providers and their ability to
deliver adequate care. Understanding this impact was essential for devising strategies to alleviate
the strain on BH providers and improve patient outcomes. This question set the stage for
exploring the broader systemic issues within the Navy’s healthcare system The section
concluded with a summary that synthesized the findings and discussed their implications for the
capacity of BH providers to meet patient needs.
Theme 1: Overwhelming Workload and Burnout
The first theme that emerged from the data was the overwhelming workload and burnout
experienced by BH providers due to the shortage of providers. Six of the 12 respondents
mentioned burnout or feeling overwhelmed. C4 noted, “We’ve conducted exit interviews with
civilian Psychologists who have quit. Their reasons are non-competitive pay and burnout they
attribute to the high proportion of high acuity patients and high administrative burden.” The
shortage has led to increased responsibilities and pressures on the existing staff, significantly
impacting their ability to provide quality care. C1 explained:
Well, it definitely impacts the ability to accept new people I mean, like back in the day,
we would have like a census of like, 100, 110 residential people [patients]. Right now, it's
like around 30 to 40, we can't take everyone, we don't have enough teams.

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This strain often forced providers to extend their working hours and take on additional
administrative tasks, further exacerbating feelings of burnout. C5 shared, “The workload is
overwhelming, and I often feel more like a glorified case manager than a clinician.” N1
summarized, "I mean, it's the commonsense response, right? If we don't have enough people,
then that means we have to see the people coming in. And we can't see everyone coming in. So,
we got to send people out." Interview findings further illustrated these issues. C6 expressed, "So
I'm, like, constantly affected by being overscheduled, not having enough space in my schedule..."
and N3 conveyed, "So I've become a case manager, I've become an overpaid case manager.
That's how I view myself." In summary, the participants' descriptions of feeling overwhelmed
and serving as 'glorified case managers' vividly illustrated how excessive workload and
administrative responsibilities led to burnout and negatively impacted their capacity to provide
quality care.
Theme 2: Difficulties in Delivering and Maintaining High-Quality Patient Care
This theme emerged and represented how the shortage of BH providers hindered the
delivery and maintenance of high-quality patient care. Five participants brought up patient care,
more specifically difficulties in providing and maintaining high-quality patient care. Due to the
insufficient number of providers, patient care had become disjointed and rushed, compromising
the effectiveness of treatments. C5 highlighted, "Due to the shortage, we often have to rush
sessions, and follow-ups are frequently inadequate, diminishing the quality of care."
Additionally, miscommunications and administrative errors were more likely to occur, causing
some patients to fall through the cracks. N6 noted, "There's been several that have fallen through
the cracks like that. Just miscommunication I guess, between like EMH’s is and putting in

69
referrals. And I think the care is super fragmented, because we're so short that we have to send
out to the network.”
The theme underscored the direct impact of the BH provider shortage on patient
outcomes and emphasized the urgent need for systemic improvements to ensure consistent and
effective care. N1 illustrated this point vividly:
But we're so poor at being able to get them in that they end up just shoving it down. And
they don't get seen or it's so bad that they end up going inpatient. So, like we're not
capturing them at the first sight of when they're like having issues, like we're capturing
them way past where we should have been helping them. (N1, 2024).
Furthermore, C6 shared, "It's disheartening to see the contrast between the Navy's stated
commitment to mental health and the reality of the BH provider shortage.”
However, there were some BH providers who felt they could still manage patient care effectively
despite the challenges. C3 mentioned, "I believe that I can adequately meet the needs of my
patients, as I am allotted sufficient time to see them.” Interview findings further supported these
insights, demonstrating the complexity and urgency of addressing the BH provider shortage to
improve patient care outcomes.
The first major theme centered around the intense workload and resulting burnout among
BH providers due to a critical shortage of providers. This shortage had increased responsibilities
and pressures on existing staff, significantly impacting their ability to provide quality care. Many
BH providers reported being overwhelmed, managing reduced patient loads and extended
working hours, which exacerbated burnout and diminished job satisfaction. The second theme
highlighted the difficulties in delivering and maintaining high-quality patient care due to
insufficient staff, leading to rushed and non-continuous treatment, administrative errors, and

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miscommunications. Some providers, despite these challenges, felt they could still meet their
patients' needs effectively, suggesting varied experiences among BH providers.
Research Question 2: How do the Various Levels of the Navy System Present Both
Obstacles and Opportunities for Hiring New BH Providers and Retaining Current BH
Providers?
This research question was pivotal as it investigated the systemic and structural
challenges that affected the recruitment and retention of BH providers within the Navy.
Understanding these layers was crucial for identifying potential improvement opportunities and
developing strategies to overcome existing barriers. This section was organized to provide a
comprehensive analysis of the identified themes from the interview data, subdivided into
obstacles and opportunities.
Obstacles for Hiring New BH Provides and Retaining Current BH Providers
Several themes emerged when discussing the obstacles the Navy faces in hiring and
retaining BH providers. These obstacles included bureaucratic inefficiencies within the civilian
hiring process, perceived job dissatisfaction among both civilian and uniformed staff, and
challenges with promotions for uniformed BH providers. These issues hinted at workplace
discontent and other related concerns, which were explored further below. Interviewees reported
that such problems significantly contributed to low recruitment rates, widespread frustration, and
higher attrition rates, thereby complicating the Navy's efforts to maintain an adequate and stable
BH provider workforce.
Theme 3: Workplace Discontent
The prevalent dissatisfaction among eight BH providers in the Navy primarily stemmed
from systemic leadership and support deficiencies, as evidenced by firsthand accounts from the

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participants. For instance, C1's observation of "toxic leadership" and the absence of remedial
action highlighted an environment where negative managerial behaviors went unchecked,
contributing to a culture of discontent. Similarly, C2 remarked on the lack of job fulfillment,
“People are leaving, because they're not feeling fulfilled in their jobs.” underscoring the
misalignment between employee expectations and job realities, a sentiment further echoed by C6
who noted a pervasive feeling of being undervalued, “So what I think the most the most of the
reason is that they don't feel valued”
Leadership's role was critically examined through the insights of C3 and C4, who
attributed resignation decisions to inadequate leadership and a perceived lack of support from
command structures. C3 noted, “It is because of their perception of non-support from the
command.” C4 added, “Uniformed BH providers are typically advanced up the leadership ladder
very quickly, before mastering their clinical or leadership skills. These people are given all
decision-making power for the vision and trajectory of the department, even though they usually
have little to no direct knowledge of the day-to-day happenings of every particular clinic” This
notion was reinforced by C5, who pointed to the "lack of support from leadership and the added
pressures of military duties" as primary factors driving resignations. Moreover, N5's comments
highlighted a broader systemic issue where BH providers felt constrained by unrealistic
expectations and misaligned priorities. This issue was exemplified by the operational challenges
associated with the Behavioral Health Data Portal (BHDP). The BHDP, an enterprise-wide web
application used by the Defense Health Agency (DHA) to enhance BH screenings and patient
care through standardized data collection and monitoring, added to the administrative burden.
Consequently, BH providers spent more time on data entry and management tasks, reducing their
ability to provide direct patient care. One respondent noted, "Unrealistic expectations of the

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department like with BHDP for example. Just, I would say that the priorities of the higher ups
don't seem to be aligned with the reality of the situation."
According to the respondents, the Navy's organizational culture requires transformation.
They suggested that enhancements in intrinsic motivators, such as recognition and achievement,
along with improvements in structural and supportive leadership elements, could significantly
mitigate these issues. Herzberg's motivation-hygiene theory offers a critical framework for
analyzing the interaction between intrinsic and extrinsic factors and their impact on job
satisfaction and retention within the Navy. This theory, introduced by Herzberg, Mausner, and
Snyderman in their foundational 1959 study, distinguishes between 'motivators' that enhance job
satisfaction, such as achievement and recognition, and 'hygiene factors' that, when inadequate,
cause job dissatisfaction, including leadership support and organizational policies. Applying this
framework allows for a more effective discernment of how these factors collectively influence
BH providers' satisfaction and retention, providing a scholarly lens to address the systemic issues
identified in this study more comprehensively (Herzberg, Mausner & Snyderman, 1959).
Theme 4: Bureaucratic Inefficiencies with the Civilian Hiring Process
Five of 12 respondents focused on the bureaucratic inefficiencies within the Navy's
civilian hiring process. They reported these inefficiencies as significantly delaying the
onboarding of new BH providers, further exacerbating the shortage. The slow and cumbersome
hiring process often results in potential candidates seeking employment elsewhere, thereby
hindering the Navy's ability to maintain an adequate workforce.
Participants highlighted several facets of these inefficiencies. C1 noted the protracted
nature of the onboarding process, even for candidates already within the Department of Defense
(DoD) system, stating, "So like I said before, the onboarding process takes way too long. Even a

73
few years ago, when I was coming from the VA [Veteran’s Affairs] system, it took me a year to
get on-boarded." C3 described experiencing disorganization and redundancy, having to "submit
the same paperwork multiple times," and faced confusion due to the absence of an onsite human
resources department. C4 further criticized the federal system's bureaucracy for its "slow and
cumbersome hiring process," which leads many candidates to abandon their applications in favor
of faster opportunities. The inefficiency is echoed in the experiences of N3 and N4, who
observed that prolonged hiring timelines often result in candidates accepting higher-paying jobs
elsewhere, typically with the VA. N4 explicitly described the HR process at the hospital as "a
nightmare," where "they take forever, and by the time they finally get the person, they've found
another job." The participants’ insights about bureaucratic inefficiencies collectively painted a
picture of a hiring system fraught with delays, which not only impeded the Navy's ability to
replenish its BH provider workforce but also contributed to broader issues of maintaining an
effective and stable infrastructure.
Theme 5: Promotion Challenges for Uniformed BH providers
Five participants noted that promotion challenges faced by active-duty BH providers
represent a significant obstacle. They discussed these challenges as stemming from the necessity
for uniformed BH providers to take on leadership roles to advance their careers, as clinical
proficiency alone is not sufficient for promotion. According to the respondents, the promotion
system within the Navy is biased against some BH providers leading to frustration and attrition.
Interview participants provided insights that underscore the perceived biases within the
promotion system. C4 pointedly criticizes the existing framework, noting, "They [Uniformed BH
providers] must take leadership roles to promote because simply being a good clinician is
insufficient. Based on the interviews, the promotion system for the uniformed BH providers is

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biased against them. “Those who do not promote are eventually fired.” This sentiment is echoed
by N1, who expresses a sense of being overlooked despite substantial efforts: “I mean, from us
an issue for certain is promotion, right? Promotions, promotions, promotions, like we are getting
passed over, we're taking on so many collaterals. But there's no, like, there's no appreciation for
us. It's kind of like keep doing all this work, but we're not going to promote you.” N2 Said “So…
you can make promotion, less of a headache.” Furthermore, N3 succinctly captures the resultant
frustration, stating, “It could be that we're not promoting and we're just leaving.”
These testimonies highlight a critical area of concern for uniformed BH providers within
the Navy's promotion system. The interviewees stated that the current criteria and processes may
not adequately recognize or reward the unique contributions of mental health professionals. This
misalignment between role expectations and promotion criteria not only hampers career
progression but also may undermine the overall morale and retention of skilled BH providers
within the Navy.
Respondent insights reveal significant systemic barriers within the Navy's organizational
structure that hinder the hiring and retention of BH providers. These challenges are evidenced by
the experiences and perceptions of the BH providers, who identify critical flaws in the system
that deter both potential and current providers. This feedback underscores the urgent need for
structural reforms to address these significant obstacles.
Participants’ discontent with their workplace emerged as a critical issue, where toxic
leadership and inadequate support structures significantly impact morale and professional
satisfaction. This discontent is exacerbated by a pervasive misalignment between job
expectations and the realities of service, as well as a general lack of recognition and support from
the command hierarchy. Such an environment not only discourages long-term commitment

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among BH providers but also fosters high attrition rates, thereby undermining efforts to maintain
a robust healthcare workforce.
Additionally, bureaucratic inefficiencies in the hiring process contribute to these
challenges by delaying the onboarding of new BH providers and deterring potential candidates,
who often opt for more agile and competitive opportunities elsewhere. The cumbersome and
protracted hiring procedures underscore a disconnect between the Navy's operational needs and
its administrative practices. Moreover, the promotion system, which prioritizes leadership roles
over clinical proficiency, further alienates highly skilled clinicians who may not wish to pursue
administrative paths. This misalignment between promotion practices and professional
inclinations exacerbates dissatisfaction and turnover among BH providers.
Despite these challenges, the interviewees also revealed how the Navy system presents
inherent opportunities to hire and retain more BH providers. By addressing the highlighted
barriers, the Navy can leverage its unique capabilities and resources to create a more supportive
and efficient environment for BH providers. This shift would not only improve current practices
but also pave the way for innovative strategies that enhance recruitment and retention.
Opportunities and Strategies for Hiring New BH Providers and Retaining Current BH
Providers
Three primary themes emerged from respondents' comments regarding opportunities for
the Navy to enhance the recruitment and retention of BH providers: competitive compensation,
effective recruitment and outreach strategies, and supportive policies for pregnant uniformed BH
providers. Interview participants highlighted that implementing targeted outreach efforts can
effectively inform potential candidates about the opportunities within the Navy, thereby
strengthening recruitment and retention initiatives. Additionally, offering competitive salaries

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and benefits was emphasized as a crucial factor in attracting new BH providers while retaining
current ones. Furthermore, developing and enforcing supportive policies for pregnant uniformed
BH providers can help mitigate career disruptions and improve job satisfaction, making the Navy
a more attractive and supportive employer.
Theme 6: Competitive Compensation and Incentives
The issue of competitive compensation emerged as a critical factor influencing the
recruitment and retention of BH providers in the Navy, as noted by five respondents. Insights
from interviews revealed that the Navy's salary and benefits structure is often perceived as noncompetitive, especially when compared to opportunities in the civilian sector or other federal
systems like the VA. This disparity not only challenges the Navy's ability to attract qualified
professionals but also opens a clear opportunity for strategic improvement. C1 succinctly
emphasizes the importance of pay in attracting talent: "At the end of the day, you know, money,
money, money, right? You pay people more, then more people will compete to kind of get the
job." Similarly, C2 and C5 highlight the necessity of aligning compensation with the value of the
work provided, with C2 noting, "That's how you demonstrate your value is you pay
commensurate to the value of the service," and C5 adding, "Offering competitive salaries that are
comparable to civilian roles is essential." C4 added, “I think the challenging dispositions and
high acuity of most cases leads to burnout and attrition, and the non-competitive pay causes
challenges in recruitment and retention.”
Additionally, C6 linked effective recruitment and retention strategies directly to the
provision of competitive benefits: "Prioritizing health through better recruitment and retention
strategies, reflected in competitive benefits and salaries, is crucial." This perspective was
reinforced by N4 and N5, who pointed out the systemic shortcomings that currently impeded the

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Navy's competitive edge. N4 stated, "But the reality is, the system does not pay enough for
[location]," and N5 observed, "A lot of civilians are going into VA because they pay more." By
addressing these gaps in compensation, the Navy could significantly enhance its capacity to
attract and maintain a highly skilled workforce. This strategic focus on improving compensation
could transform a current weakness into a strength, potentially increasing retention rates and
positioning the Navy as a more attractive employer in the healthcare industry.
Theme 7: Enhancing Recruitment through Community Outreach Initiatives
Four interviewees specifically mentioned that the recruitment process, alongside
community outreach and engagement strategies, is crucial for attracting BH providers to the
Navy.C4 points out the core issues with incentives and competitive positioning, “They also limit
recruitment incentives and salaries, making them non-competitive to most applicants unless there
are extenuating circumstances affecting their desire to work here.” This sentiment highlights a
fundamental misalignment between the Navy’s offerings and market expectations, which if
addressed, could significantly boost recruitment effectiveness.
Furthermore, C6 emphasized the shortcomings in community engagement and marketing:
“I can speak to the civilian part, of course, um, so I think that it's, the challenges are community,
you know, marketing.” This perspective was echoed by N2, who criticized the current fiscal
approach to hiring: “So I think there are things like that where you know, or we need to stop
being cheap, and hire people.” N6 succinctly summarized the overarching challenge: “So number
one, I think is the inability to recruit. And maybe the inability to retain, but I think the big part is
the inability to recruit.” By addressing these identified gaps in recruitment strategies, enhancing
marketing efforts, and offering competitive incentives, the Navy could improve its ability to
attract and retain top talent. Implementing these changes could not only transform the Navy's

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recruitment process but also bolster its overall effectiveness in maintaining a robust BH provider
workforce.
Theme 8: Supportive Policies for Pregnant BH Providers
The discussions surrounding the unique challenges faced by pregnant female uniformed
BH providers in the Navy revealed significant issues that intertwined operational demands with
personal health needs—a situation not commonly encountered in civilian healthcare settings.
This was discussed by two of the twelve participants, specifically two out of five female
uniformed BH providers. According to the DoD (2022), the policy of reassigning female BH
providers on sea-duty to shore-based roles upon pregnancy was necessary for health and safety
reasons but introduced complex career and personal challenges. According to participant reports,
these reassignments influenced not only the professional trajectories of these BH providers but
also significantly affected their personal lives and family planning decisions, indicating a critical
area where supportive adjustments were necessary.
Interview findings provide personal insights into the profound implications of these
policies. N1 shares a poignant example of the challenges faced, "As a female, God forbid, you
want kids and a family. I know counterparts whose lives are miserable because they had to come
back early from maternity leave and found their key billets reassigned without their knowledge."
This testimony underscores the disruption to career progression and personal stability that can
result from the current approach to maternity-related reassignments. Similarly, N3 illustrates the
tension between career obligations and family planning within the military context:
The time I went to the [redacted] was around the time my husband and I were trying to
have a baby... So, do you remember [redacted]? Yeah, yeah, she said, 'Just get just get
pregnant.' And like, I mean, it was around the time we were trying, and my husband was

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like, 'You better not do that shit. Because I fucking hate it when women do that.' And so,
there's kind of this pressure of like, you know, if I would have gotten pregnant one.
Would people call me 'Oh, look at that fucking lazy bitch.' And then number two, what
about the sailors that needed me?" This narrative reveals the social pressures and moral
dilemmas that compound the challenges faced by female BH providers considering
pregnancy.
These firsthand accounts illustrate the need for more nuanced and supportive policies that can
better balance the professional obligations and personal health needs of pregnant BH providers,
ensuring that their career progression and personal well-being are not unduly compromised.
Based on respondent feedback, several opportunities were identified to enhance the
recruitment and retention of BH providers in the Navy. Key areas for improvement included
offering competitive compensation, refining recruitment strategies, and implementing supportive
policies for pregnant BH providers. Adjusting salary and benefits to match or exceed those
offered in the civilian sector and other federal agencies could make Navy positions more
attractive. Additionally, enhancing recruitment efforts through effective marketing and
community outreach could increase awareness and interest among potential BH providers.
Support for pregnant BH providers also emerged as a critical area for development. By creating
more accommodating policies, the Navy could ensure that career progression and personal wellbeing were not compromised by pregnancy, thus enhancing job satisfaction and retention.
These strategic opportunities, as highlighted by the subjects, suggested that addressing
these specific areas could significantly improve the Navy's capability to attract and retain skilled
BH providers. Moving forward, the insights gathered from these discussions would guide the

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exploration of the final research question, focusing on systemic enhancements and long-term
strategies to sustain and advance Navy healthcare services.
Research Question 3: What Strategies Can the Navy Health System Implement to
Enhance BH Care for Navy Beneficiaries Despite the Global
Shortage of BH Providers?
Addressing this final research question was essential for identifying actionable strategies
that could enhance the Navy’s ability to provide comprehensive BH services amidst a global
shortage of BH providers. The significance of this question lies in its potential to uncover
practical solutions that could mitigate the adverse effects of the shortage, thereby ensuring that
service members and their families receive the necessary mental health support. This section
delved into the themes related to Navy administrative processes, hiring more paraprofessionals,
and adopting more innovative ways to treat BH patients. By exploring these themes, a
comprehensive understanding of the multifaceted challenges faced was gained, and a strategic
approach to overcome them could be developed. The insights derived from this analysis would
inform policy changes and operational improvements that could strengthen the Navy’s BH
services, ultimately enhancing the overall readiness and well-being of its personnel. This
thorough examination would provide a roadmap for addressing the systemic issues that impeded
the effective delivery of mental health care within the Navy.
Theme 9: Streamlining Administrative Processes
Five of 12 participants mentioned streamlining administrative processes being essential
for enhancing BH treatment opportunities within the Navy. Based on the interview responses, the
extensive ancillary administrative responsibilities placed on providers significantly detract from

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their ability to deliver direct patient care. By minimizing these additional administrative burdens,
BH providers can focus more on their primary role of providing high-quality care to patients.
Respondents underscored the impact of administrative tasks on their clinical efficiency.
C4 noted how the administrative work impacted them, "A higher percentage of cases requires
additional administrative work like interacting with patients’ commands, engaging with the MEB
[Medical Evaluation Boards] division, writing medical boards or writing recommendations for
administrative separation or clinical management caring for high acuity patients that reduces the
number of patients that each provider can manage and treat effectively." C5 highlighted the
inefficiencies of the MHS Genesis Electronic Health Record (HER) system, stating, "The MHS
Genesis EHR system is cumbersome and inefficient. Improving this system would free up more
time for patient care." This sentiment was echoed by N1, who remarked, "Because really all
we're doing as providers is managing med boards..." N4 shared their surprise at the extensive
ancillary administrative responsibilities expected of providers: "I was unprepared for the
extensive ancillary administrative responsibilities expected of providers." N6 elaborated on the
frustration with bureaucratic processes:
Okay, frustration with the bureaucracy, all the paperwork, the notes, we do hear coming
from the civilian sector, where you see, like 24 patients a day, and it's just like, click,
click, click, click, click written onto the next. And these notes can take upwards of 30
minutes to an hour, and then you have to submit a med board, which takes even longer. I
mean, it's really administratively heavy.
C2 suggested the potential benefits of integrating artificial intelligence (AI) and virtual health: "I
think that some of the things that I've seen the DHA leaders talk about are on point in terms of

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we need to use AI. We need to be using virtual health. I would invest it in [for] compensation,
training."
These insights highlighted the critical need to streamline administrative processes within
the Navy. By reducing paperwork, leveraging AI for documentation, and refining existing
systems, providers could be freed up to focus more on patient care. This would significantly
improve the overall quality and efficiency of BH services.
Theme 10: Hiring More Paraprofessionals
Six out of 12 interviewees responded favorably when asked if hiring more
paraprofessionals could help mitigate the shortage. The interviews revealed a range of opinions
on this matter. Some respondents suggested that paraprofessionals, such as Psychiatric Health
Technicians (also referred to as Behavioral Health Technicians or BHTs) and Substance Abuse
Counselors, could provide valuable support and alleviate some of the workload from BH
providers. For instance, C5 noted, "I agree that employing more paraprofessionals can help. They
can handle many of the tasks that don't require a licensed psychologist, such as initial
assessments, group therapy sessions, and administrative support. This would free us up to focus
on more complex clinical tasks and reduce overall workload."
However, other contributors expressed concerns about relying too heavily on
paraprofessionals and the potential impact on the quality and complexity of care required. N4
highlighted this apprehension, stating, "Okay, so every note we write has to have a duty
disposition. And Substance Abuse Counselors and BHTs can't provide that, right. At the end of
the day, they still must be screened by us. Implemented correctly, yes, it would work. Do I have
any faith in the Navy implementing it correctly? No." This discussion emphasized the

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importance of finding a balanced approach to integrating paraprofessionals into the mental health
care system to ensure both support for BH providers and the maintenance of high-quality care.
These insights underscored the need for a balanced and well-implemented strategy in
integrating paraprofessionals to support BH providers effectively while maintaining the quality
of care. Ensuring proper training and utilization of paraprofessionals was crucial in finding this
balance. This approach could help mitigate the BH provider shortage and enhance the overall
efficiency of mental health services in the Navy. Building on this foundation, the exploration of
different patient care delivery models presented another promising avenue for improving BH
outcomes.
Theme 11: Innovative Approaches to BH Services in the Navy
When asked, “Besides an increase in hiring or recruiting, what else do you think can be
done to provide the best BH treatment to Navy beneficiaries despite the shortage?” five
respondents suggested various alternative strategies. A prominent theme that emerged during the
interviews was the exploration of more modern ways to deliver patient care. The providers
suggested transitioning from traditional one-on-one therapy to group therapy approaches, which
could enhance the efficiency and reach of mental health services. Groups were specifically
mentioned by three interviewees. C4 highlighted this shift, stating, "Implement more treatment
groups, reduce paperwork burden for BH providers or enlist other professions to help with it.”
Additionally, the potential of expanding remote and telehealth capabilities was emphasized to
provide greater access to care, especially for those in remote locations. C1 remarked on this
trend, noting, “But another way, you know, like I see a lot of it happening lately is remote 100%
remote work.” This sentiment underscored the growing acceptance and feasibility of remote
mental health services within the Navy. Leveraging AI technology was also mentioned as a

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promising tool to support BH providers in delivering more effective and timely interventions. C2
supported this view, stating, “I think that some of the things that I've seen the DHA leaders talk
about are on point in terms of we need to use AI. We need to be using virtual health.” C4 echoed
the statement about the importance of AI when they said, “use AI to help with some of the
paperwork such as clinical documentation." These insights suggested that adopting innovative
care delivery models, such as group therapy, telehealth, and AI integration, could significantly
enhance the effectiveness and accessibility of BH services in the Navy.
These approaches not only promised to improve the efficiency of care but also ensured
that mental health services were more accessible to Navy personnel, regardless of their location.
Implementing these modern care delivery models could play a crucial role in overcoming current
challenges and setting a new standard for mental health care in the military. By adopting group
therapy, expanding telehealth capabilities, and leveraging AI technology, the Navy could
enhance the quality and reach of its BH services. These innovations would ultimately contribute
to a more resilient and effective healthcare system for service members.
Summary of Findings
The findings from this study revealed several key themes regarding the shortage of BH
providers in the Navy and the impact on patient care. The first research question highlighted how
the overwhelming workload and burnout experienced by existing BH providers significantly
impaired their capacity to meet patient needs and accept new patients. This issue was
exacerbated by the extensive administrative responsibilities that detracted from clinical duties,
leading to fragmented and rushed care.
The second research question identified systemic obstacles and opportunities within the
Navy's healthcare system. Bureaucratic inefficiencies in the civilian hiring process and

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promotion challenges for uniformed BH providers were major barriers to recruitment and
retention. Conversely, opportunities for improvement were seen in competitive compensation,
targeted recruitment/outreach strategies, and supportive policies for pregnant uniformed BH
providers.
Addressing the third research question, the study found that streamlining administrative
processes, hiring more paraprofessionals, and adopting innovative patient care delivery models
were essential strategies to enhance BH services. Streamlining administrative tasks could reduce
the burden on providers, allowing them to focus more on patient care. Hiring paraprofessionals
could help alleviate workload pressures by handling fewer complex tasks, thus supporting BH
providers in delivering more effective care. Additionally, adopting innovative models of patient
care, such as telehealth and group therapy, could expand access and improve the efficiency of
mental health services, which was crucial given the global shortage of providers. Chapter Five
will present recommendations for addressing these findings through evidence-based strategies,
aiming to improve the recruitment, retention, and overall effectiveness of BH providers within
the Navy's healthcare system.

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Chapter Five: Discussion and Recommendations
This chapter presents a comprehensive discussion of the study's findings, linking them to
the literature reviewed in Chapter 2 and interpreting them through Bronfenbrenner's ecological
systems theory (Bronfenbrenner, 1979). It then provides evidence-based recommendations for
practice, integrated recommendations for a comprehensive program, limitations and
delimitations of the study, suggestions for future research, and implications for equity. The
chapter concludes with a synthesis of key insights and proposed actionable steps.
Discussion of Findings
The findings from this study reveal a multifaceted and deeply interconnected set of
challenges affecting the recruitment, retention, and effectiveness of BH providers within the
Navy. Firstly, the overwhelming workload and resulting burnout among BH providers were
identified as critical issues that severely impact their ability to provide high-quality care. This
was compounded by systemic inefficiencies and bureaucratic obstacles, particularly in the hiring
and promotion processes, which further exacerbated staff shortages and reduced morale.
Additionally, the study highlighted significant difficulties in maintaining continuity and quality
of patient care, as the fragmented and inconsistent nature of current service delivery undermines
treatment effectiveness. These challenges were not isolated but rather deeply intertwined with
the broader systemic and organizational structures of Navy healthcare, underscoring the
necessity for comprehensive and integrated solutions. The alignment of these findings with
Bronfenbrenner's (1979) ecological systems theory provides a robust framework for
understanding the complex dynamics at play, emphasizing the need for interventions at multiple
levels to address these pervasive issues effectively.

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Consequences of Excessive Workload on BH Providers
The findings indicate that BH providers in the Navy are under significant stress due to
excessive workloads, which not only impairs their ability to function effectively but also leads to
high rates of burnout. Participants frequently mentioned feeling overwhelmed by the volume of
their responsibilities, reflecting similar issues highlighted in broader studies on healthcare
provider stress and job satisfaction (Moitra et al., 2022; Stewart, 2019). The excessive workload
has resulted in a shift from clinical duties to administrative tasks, as participants in this study
described spending a significant portion of their time on non-clinical activities such as extensive
paperwork and managing bureaucratic processes (Cisneros, 2022a). This administrative burden
detracts from their ability to provide quality care and contributes to fragmented and inconsistent
service delivery.
Utilizing Bronfenbrenner's ecological systems’ theory, the concept of the mesosystem
captures how the interactions between different environments, such as workplace contexts and
professional roles, fundamentally influence overall job efficacy and satisfaction. The
administrative burdens described by participants in this study contribute to increased stress and
reduced morale among BH providers (Defense Health Board, 2007). Addressing these systemic
inefficiencies is crucial for improving both the well-being of providers and the quality of care
delivered to service members (Donovan, 2020b). By streamlining administrative processes and
reducing non-clinical tasks, the Navy can enhance the working conditions for BH providers,
leading to better patient outcomes and higher job satisfaction among healthcare providers.
Systemic Obstacles to BH Provider Recruitment and Retention
This section delves into the systemic inefficiencies that hinder the recruitment and
retention of BH providers within the Navy. The bureaucratic challenges in the hiring process, as

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documented by participants in this study, reflect broader issues within the Department of
Defense’s recruitment apparatus. Participants highlighted extensive delays and redundancies in
the hiring process, which often led to candidates accepting positions elsewhere due to prolonged
wait times. These systemic obstacles create significant delays, discouraging potential candidates
and exacerbating the shortage of qualified professionals, as documented in a separate report by
Cisneros (2022a).
Promotion challenges for uniformed BH providers were also highlighted, with
participants noting that leadership roles were often prioritized over clinical expertise. This
finding aligns with Stewart (2019), who observed that the promotion system for uniformed BH
providers often led to frustration and attrition. Participants expressed that the current promotion
system does not adequately recognize clinical excellence, leading to a sense of underappreciation
among clinicians focused on patient care. The emphasis on leadership roles over clinical skills
can demoralize clinicians who prefer to focus on direct patient care rather than administrative
duties. Drawing from the principles of Bronfenbrenner's ecological systems theory, it can be
understood that broader environmental factors, such as organizational policies and procedures,
play a crucial role in shaping individual work experiences and career choices, often intensifying
existing challenges. Addressing these systemic inefficiencies is essential for improving both
recruitment and retention, ultimately enhancing the quality of BH services provided to Navy
personnel (Defense Health Board, 2007; Donovan, 2020b).
Compensation as a Lever in BH Workforce Expansion
Competitive compensation was identified as a critical factor in the study's investigation
of the challenges affecting the recruitment and retention of BH providers, highlighting its
essential role in addressing workforce shortages. Participants reported that the Navy struggled to

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offer competitive salaries with those in the private sector or other federal entities such as the VA.
The compensation packages within the Navy were often cited as inadequate, especially when
compared to the higher salaries and comprehensive benefits offered by civilian employers and
other government agencies. This finding is supported by Donovan (2020b), who found that
despite recent increases in special and incentive pay, the Navy's compensation packages still
lagged behind those of other employers, making it difficult to attract and retain qualified BH
providers.
Participants highlighted that the pay disparity was particularly pronounced for civilian
BH providers who could often find better compensation in other government agencies or private
practice. This challenge was compounded by the high cost of living in certain duty locations and
the burden associated with military service, which further dissuaded potential recruits and
retention efforts of active BH providers. Moreover, Stewart (2019) pointed out that
noncompetitive pay structures, combined with operational and relocation demands, significantly
hindered the Navy's ability to maintain a stable and experienced workforce. Addressing these
compensation issues is crucial for ensuring that the Navy can attract and retain a capable BH
workforce, ultimately improving the quality of care provided to service members.
Innovative Solutions for Broadening Access to Behavioral Health in Response to BH
Provider Shortages
The exploration of innovative solutions for broadening access to BH services emerged as
a promising strategy in the study. Participants discussed telehealth as an opportune approach,
expressing a preference for telehealth over traditional methods, attracted by its flexibility which
is well-suited to the dynamic nature of military life. Moreover, the ample remote job
opportunities in organizations such as the VA were highlighted as particularly enticing for BH

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providers seeking better work-life balance. This finding is supported by Moitra et al. (2022), who
demonstrated that telehealth improves access to care and reduces costs, making it a viable
solution for expanding BH services in the Navy.
Participants also highlighted the potential benefits of utilizing paraprofessionals, such as
behavioral health technicians (BHTs) and substance abuse counselors, to support BH providers
and alleviate their workload. The inclusion of paraprofessionals can help manage routine tasks,
allowing licensed providers to focus on more complex clinical duties. This strategy aligns with
findings from RAND (2019), which emphasized the role of mid-level providers in addressing
workforce shortages and enhancing service delivery. Implementing these innovative solutions is
essential for optimizing the Navy's BH services and ensuring that service members receive
timely and effective care.
Recommendations for Practice
Based on the study's findings, several key recommendations aim to address the critical
challenges impacting the recruitment, retention, and effectiveness of BH providers within the
Navy. These recommendations are grounded in the empirical data collected and supported by
existing literature, providing a robust framework for actionable solutions. The following
recommendations aim to streamline administrative processes, enhance telehealth services,
improve competitive compensation, effectively utilize paraprofessionals, and implement
supportive policies for pregnant BH providers. Each recommendation is designed to target
specific findings from the study and collectively contribute to a more efficient and supportive
environment for Navy BH providers. Although the findings were diverse, when there was some
agreement, it emerged as a recommendation, ensuring that the proposed solutions are reflective
of both commonalities and key differences in perspectives.

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Recommendation 1: Streamline Administrative Processes through Artificial Intelligence
(AI) Integration
Forty-two percent (five out of twelve) of interviewees highlighted the significant impact
of administrative burdens on their clinical efficiency. They noted that the extensive time spent on
paperwork and bureaucratic processes detracts from their ability to provide quality care. This
observation aligns with research indicating that administrative tasks are a major source of stress
and inefficiency in healthcare settings (Shanafelt et al., 2016; West et al., 2018). The respondents
emphasized that reducing these burdens is essential for improving the effectiveness of BH
services in the Navy. To address the administrative burden, the recommendation is to streamline
administrative processes by integrating Artificial Intelligence (AI) into the DoD’s Electronic
Health Record (EHR) system, Military Health System (MHS) Genesis, and other related
programs such as the Behavioral Health Data Portal (BHDP). Leveraging AI can automate
repetitive data management and record-keeping tasks, allowing BH providers to focus more on
patient care. Twenty-five percent (three out of twelve) of respondents specifically mentioned the
potential benefits of AI in improving efficiency. Studies have shown that reducing administrative
burdens can significantly improve provider satisfaction and patient outcomes (Shanafelt et al.,
2016; Shanafelt et al., 2019; West et al., 2018). By investing in AI technology to enhance the
existing EHR system, the Navy can significantly streamline processes and improve the overall
efficiency of BH services, ultimately enhancing care quality and accessibility for service
members.
Recommendation 2: Expand Telehealth Services
Forty-two percent (five out of twelve) of respondents suggested various alternative
strategies for providing the best BH treatment to Navy beneficiaries despite the shortage. A

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prominent theme that emerged was the need to expand telehealth capabilities to mitigate the
impact of the BH provider shortage by providing greater access to care, particularly for service
members in remote locations. This observation aligns with research indicating that telehealth can
significantly reduce wait times and improve patient satisfaction (Connolly et al., 2020; Moitra et
al., 2022). Cisneros (2022a) also emphasizes the importance of telehealth in expanding access to
care and overcoming geographic barriers.
Expanding tele-behavioral health (TBH) capabilities would enable the Navy to fill gaps
in care delivery and ensure that service members receive timely and effective treatment. Altschul
et al. (2018) highlighted that telehealth can be a critical tool in addressing workforce shortages
by maximizing the reach of existing providers. Five respondents emphasized the potential of
expanding remote and telehealth capabilities to enhance care accessibility and efficiency. By
investing in robust telehealth infrastructure, including training for providers and ensuring service
members have access to the necessary technology, the Navy can enhance the efficiency and
effectiveness of its BH services. These innovations would ultimately improve the well-being and
readiness of its personnel, setting a new standard for mental health care in the military.
Recommendation 3: Enhance Recruitment and Retention through Competitive
Compensation
Forty-two percent of respondents (five out of twelve) indicated that competitive
compensation is a critical factor influencing the recruitment and retention of BH providers in the
Navy. Addressing this issue is essential for maintaining a robust workforce of qualified BH
providers. Research supports that competitive salaries and benefits are crucial in reducing
turnover and enhancing job satisfaction among healthcare providers (Donovan, 2020b). To
effectively address the critical shortage of BH Providers, it is essential for the Navy to implement

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proactive recruitment strategies. By establishing partnerships with academic institutions and
creating internship or residency programs, the Navy can develop a robust pipeline of qualified
candidates. Additionally, enhancing visibility through targeted advertising for the Navy's
Uniformed Services University of the Health Sciences (USUHS) will not only draw students
interested in a career in military medicine but also emphasize the Navy’s unique benefits and
commitment to supporting BH providers. Such strategic engagement at college campuses and
professional conferences is crucial to expanding the Navy's reach and attracting a diverse pool of
candidates, thereby ensuring a sustained influx of skilled professionals ready to meet the Navy’s
needs.
Enhancing retention efforts involves not only offering competitive pay but also ensuring
a supportive work environment and opportunities for career advancement. Implementing special
and incentive pay increases, as authorized by the William M. (Mac) Thornberry National
Defense Authorization Act (NDAA) for FY 2021, is essential for attracting and retaining
qualified BH providers. Additionally, offering bonuses for both recruitment and retention can
provide further motivation for BH providers to join and stay with the Navy. Research indicates
that competitive salaries and bonuses are strongly associated with lower turnover intentions
among healthcare providers (Donovan, 2020a). The Navy should regularly review and adjust
compensation packages, including salaries and bonuses, to remain competitive in a dynamic job
market. Participants highlighted the need for more effective retention strategies, such as
providing professional development opportunities and creating a positive work culture. Studies
show that healthcare providers are more likely to stay in positions where they feel valued and
have opportunities for growth (Cortex Healthcare, 2023; Nurseline Healthcare, n.d.). By ensuring
that pay rates reflect the high demands and responsibilities of BH provider roles and

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implementing supportive policies for career progression and work-life balance, the Navy can
better attract and retain skilled professionals, ultimately enhancing the quality of care for service
members (Cisneros, 2022a).
Recommendation 4: Develop and Utilize Paraprofessionals
Six out of 12 interviewees expressed support for expanding the role of paraprofessionals,
such as Behavioral Health Technicians (BHTs) and Substance Abuse Counselors, to alleviate the
shortage of BH providers in Navy healthcare settings. Research indicates that integrating midlevel providers can effectively increase healthcare capacity and reduce workload pressures on
licensed professionals (Cisneros, 2022a; Donovan, 2020a; Chapman et al., 2018; RAND, 2019).
This approach can allow licensed professionals to concentrate on complex clinical tasks by
providing paraprofessionals with targeted training and clear role definitions. Ensuring
paraprofessionals work to the full extent of their capabilities is critical to optimizing their
contribution and relieving burdens on BH providers. However, rigorous implementation is
essential to maintain care standards and mitigate potential challenges in care complexity
Recommendation 5: Implement Supportive Policies for Pregnant BH Providers
Two of the eight female participants discussed the challenges faced by pregnant female
uniformed BH providers in the Navy, particularly regarding policies that mandate reassignment
of sea-duty BH providers to shore-based roles upon pregnancy. This policy, while aimed at
ensuring health and safety, often disrupts career trajectories and personal lives. To address these
issues, implementing supportive policies tailored to accommodate the needs of pregnant BH
providers is crucial. Research underscores the effectiveness of such policies in other
organizational contexts, including flexible work schedules, extended maternity leave, and on-site
childcare, which have been shown to enhance job satisfaction and reduce turnover (Reese, 2020).

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By adopting similar supportive measures, the Navy can mitigate career disruptions, improve job
satisfaction, and foster a more inclusive and supportive environment for pregnant BH providers,
aligning with organizational goals of retention and workforce management.
Integrated Recommendations
The integrated recommendations aim to create a comprehensive program addressing the
identified issues holistically. Grounded in Bronfenbrenner's theory, which emphasizes the
interconnectedness of various systems influencing individuals (Bronfenbrenner, 1979), these
recommendations seek to improve the recruitment, retention, and effectiveness of BH providers
within the Navy. The proposed comprehensive program includes the following components:
Streamlining Administrative Processes Through AI Integration
To reduce paperwork and improve clinical efficiency, integrating AI-friendly technology
into the Military Health System (MHS) Genesis, the DoD's EHR, is crucial. Leveraging AI can
automate repetitive data management and record-keeping tasks, allowing BH providers to focus
more on patient care. Additionally, AI can be effectively utilized in data programs like the
Behavioral Health Data Portal (BHDP), further enhancing system functionality and efficiency.
In the context of Bronfenbrenner's ecological systems theory (1979), the mesosystem
reflects how interactions among various environments impact individual actions and
development in a range of contexts. For BH providers, this includes their direct interactions with
administrative staff and the technological tools they use. Integrating AI within the EHR system
and BHDP can streamline these interactions, reducing administrative burdens and improving
workflow efficiency. This change enhances the support system around BH providers, enabling
them to dedicate more time to direct patient care, thus improving overall clinical effectiveness.

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Expanding Telehealth Services
Investing in telehealth infrastructure and training is essential to enhance access to care for
service members in remote locations. Telehealth can significantly reduce wait times and improve
patient satisfaction, providing timely and effective treatment (Cisneros, 2022a; Connolly et al.,
2020; Moitra et al., 2022). The integration of tele-behavioral health (TBH) capabilities can help
fill gaps in care delivery and ensure comprehensive treatment for all service members.
The exosystem, according to Bronfenbrenner's model, involves the broader social
systems that indirectly affect an individual (Bronfenbrenner, 1979). For BH providers, the
exosystem includes the policies, infrastructure, and technological advancements that support
telehealth implementation. Enhancing telehealth services influences the exosystem by ensuring
that external factors, such as access to remote healthcare, are addressed. This enables BH
providers to provide continuous and effective care to service members, regardless of their
geographic location.
Enhancing Recruitment and Retention Through Competitive Compensation
Regularly reviewing and adjusting compensation packages, including salaries and
bonuses, is vital to remain competitive in a dynamic job market. This strategy includes proactive
recruitment at academic institutions and professional conferences, as well as targeted advertising
for the Navy's Uniformed Services University of the Health Sciences (Cisneros, 2022a;
Donovan, 2020b). Competitive compensation, combined with bonuses for recruitment and
retention, can significantly enhance the Navy's ability to attract and retain skilled BH providers.
The macrosystem encompasses the broader societal and economic contexts that influence
an individual (Bronfenbrenner, 1979). For BH providers, the macrosystem includes legislative
support, military policies, and economic conditions that determine compensation structures and

97
recruitment strategies. By aligning compensation with market standards and enhancing
recruitment efforts, the Navy can navigate these macro-level influences more effectively. This
ensures that BH providers are adequately compensated and that the Navy remains competitive in
attracting and retaining qualified professionals.
Utilizing Paraprofessionals
Enhanced training programs for paraprofessionals, alongside clear definitions of their
roles, are vital for effectively supporting BH providers, thereby increasing service capacity and
reducing provider burnout (RAND, 2019). By integrating paraprofessionals, such as behavioral
health technicians (BHTs) and substance abuse counselors, into behavioral healthcare teams,
many routine tasks can be delegated, which do not necessitate a licensed psychologist's expertise.
This delegation allows BH providers to concentrate on more complex and demanding clinical
responsibilities. Ultimately, such strategic utilization of paraprofessionals improves the overall
delivery of care, enhancing the efficiency and effectiveness of healthcare services within the
Navy.
The microsystem involves direct interactions within an individual's immediate
environment (Bronfenbrenner, 1979). For BH providers, the microsystem includes their day-today interactions with paraprofessionals. By integrating paraprofessionals into the care team, BH
providers receive essential support, which enhances their capacity to manage complex clinical
tasks and reduces burnout. This system level is critical because it focuses on the immediate work
environment where direct care and interaction occur, significantly impacting the daily functions
and efficiency of BH providers.

98
Supporting Pregnant BH Providers
Developing and enforcing family-friendly policies, such as flexible work schedules,
extended maternity leave, and on-site childcare, can significantly improve job satisfaction and
retention rates. These policies ensure that career progression and personal well-being are not
compromised, as they provide pregnant uniformed BH providers with the necessary support and
flexibility to balance work and family responsibilities. By implementing such supportive
measures, organizations foster a more inclusive and accommodating work environment for
pregnant uniformed BH providers, thereby enhancing overall employee morale and loyalty.
Within the microsystem, which encompasses the immediate work environment of
pregnant BH providers, there exists a crucial opportunity to directly support their needs
(Bronfenbrenner, 1979). Implementing family-friendly policies not only demonstrates
organizational commitment to employee well-being but also significantly impacts daily
interactions and support systems available to pregnant uniformed BH providers. By ensuring that
their well-being and career progression are not compromised, this supportive environment within
the microsystem plays a vital role in enhancing job satisfaction and ultimately contributes to
higher retention rates.
Implementation Sequence
A structured sequence of immediate, medium-term, and long-term initiatives is proposed
to enhance the BH system within the Navy. This strategic roadmap, informed by
Bronfenbrenner's (1979) ecological systems theory aims to ensure a sustainable and effective
standard of care for service members. In the initial 0-6 months, efforts will focus on integrating
AI solutions to streamline administrative processes and piloting telehealth service expansion,
including feasibility studies, infrastructure assessment, and staff training. Transitioning to the

99
medium-term phase spanning six to 18 months, the emphasis will be on scaling up telehealth
services, reviewing compensation packages, and launching targeted recruitment campaigns to
enhance retention efforts. Beyond 18 months, the focus will shift to expanding training programs
for paraprofessionals and developing supportive policies for pregnant uniformed BH providers.
By following this strategic implementation sequence, the Navy aims to address various levels of
influence on BH providers' work and well-being, ultimately enhancing the overall effectiveness
of the BH system and ensuring the well-being of service members.
Limitations and Delimitations
My study focused on exploring the experiences of BH providers at NHL. To ensure
clarity and a thorough understanding of the study's scope, it is essential to discuss both the
limitations and the delimitations that outline the research framework and inherent constraints.
Limitations in research referred to the factors that might have affected the accuracy or
interpretation of the study's findings (Bem, 2004; Labaree, 2016). These limitations were an
inevitable aspect of every study, and this study was no exception. Three specific limitations that
were present in this study were sample representativeness, participant reticence, and
triangulation. Delimitations were also present. Delimitations in research establish the specific
boundaries and parameters within which a study is conducted to ensure that the results are
interpretable and relevant to the specific research question or hypothesis (McGreggor, 2018). The
following section outlines the main delimitations of the study, including its focus solely on
psychologists at NHL, the limitation to this single location, and the exclusion of specific
demographic groups, which collectively define the scope and guide the interpretation of the
findings

100
Limitations
The present study was subject to several limitations, one of which pertained to the
restricted pool of potential participants that were sampled. In particular, the limited availability
of uniformed BH providers at NHL, due to their deployment, presented a considerable challenge.
This limitation had the potential to impact the representativeness of the sample, and
consequently, might have affected the generalizability of the findings. Given that some of the
uniformed BH providers at NHL were on deployment, it was uncertain whether they would be
available to participate in the study, which further exacerbated the challenge of ensuring a
representative sample of the entire population of uniformed BH providers at NHL. Therefore, the
potential implications and limitations of this challenge should be considered when interpreting
the findings of this study. Furthermore, this limitation called into question the extent to which the
findings could be applied to the broader population of uniformed BH providers, both at NHL and
within the larger Navy (Cisneros, 2022a; Donovan, 2020a; Stewart, 2019).
Another significant limitation of this study was the potential for participants to be reticent
in their willingness to openly discuss the subject matter being studied. Despite the
implementation of measures to safeguard participant confidentiality and protect individual
privacy, there remained the possibility that some participants might have been hesitant to provide
sensitive information (Dundon & Ryan, 2010). It was also important to note that this study was
not conducted under the auspices of the Department of Defense or the government, but rather for
the personal benefit of the researcher. As such, the findings of this study did not have any direct
impact on the careers of the respondents within the Navy.
One final limitation of this study pertained to the concept of triangulation, as defined by
Merriam and Tisdell (2016) as the utilization of multiple data collection methods, sources,

101
theories, and investigators to increase the validity and reliability of the research findings. In this
study, only a single qualitative data collection method was employed, which might have limited
the ability to triangulate data and enhance the robustness of the findings. Furthermore, the
sample was restricted to BH providers at a specific location, NHL, which might not have been
representative of the experiences of BH providers in other locations within the Navy. This raised
questions about the generalizability of the findings to BH providers in other regions or overseas
locations. Additionally, as the sole investigator, my own biases and perspectives might also have
impacted the results of the study, highlighting the need for multiple perspectives and
investigators in this research area.
Delimitations
Delimitations in research establish the specific boundaries and parameters within which a
study is conducted to ensure that the results are interpretable and relevant to the specific research
question or hypothesis (McGreggor, 2018). This study also included several delimitations that
were introduced to clearly define its scope and focus. By clearly identifying and acknowledging
these delimitations, the study provided a more comprehensive and nuanced understanding of the
research and its potential implications. These delimitations were crucial in understanding the
limitations and potential implications of the findings and should be considered when interpreting
the results of the study.
One key delimitation was the decision to focus solely on psychologists, both uniformed
and civilian, at NHL. Although there were social workers, psychiatrists, and psychiatric nurse
practitioners at the hospital, this study chose to focus on psychologists because they made up the
largest portion of BH providers at NHL. This delimitation helped to provide a more in-depth

102
examination of the specific experiences of this group but also limited the generalizability of the
findings to other types of BH providers.
The decision to delimit the study to a single location at NHL was a deliberate
delimitation made by the researcher to focus the scope of the study and provide a more in-depth
examination of the specific context of the research site. However, it I important to acknowledge
that this delimitation might also have limited the generalizability of the findings to other
locations or settings. Furthermore, this delimitation might also have limited the diversity of
perspectives and experiences represented in the study, as the pool of potential participants was
limited to those working at the designated study site. Despite these limitations, the researcher
believed that the in-depth examination of the specific context at NHL would provide valuable
insights into the topic of the study. In conclusion, the choice to focus on a single study site
served as a delimitation that helped to define the scope and focus of the research but also had the
potential to limit the generalizability and diversity of the findings. As the study progressed, it
was important for the researcher to consider the potential impact of this delimitation on the
interpretation of the findings.
In addition to the study site delimitation, another delimitation was that the study did not
explore the unique experiences of any specific race, gender, or sexuality, nor did it focus on any
marginalized groups. It was important to note that the decision to not explore the experiences of
specific races, gender, or sexuality, and to delimit the study solely to BH providers was not a
reflection of a lack of recognition of the importance of understanding the unique experiences and
perspectives of marginalized groups. However, this delimitation allowed me to focus on a
specific population and provide a more in-depth examination of their experiences. This
delimitation also acknowledged the limitations of the study and allowed the researcher to

103
recognize the need for further research to explore the experiences of marginalized groups. I was
aware that this delimitation might have limited the generalizability of the findings to other
populations. Despite these limitations, this delimitation served as a crucial aspect of defining the
scope and focus of the research. It was anticipated that the findings of this study would
contribute to a deeper understanding of the subject matter and serve as a basis for further
investigations into the experiences of marginalized individuals within the BH provider
profession.
In conclusion, as the researcher of this study, I acknowledge the limitations and
delimitations that were imposed upon the investigation. Despite these constraints, by recognizing
and addressing these limitations and delimitations, I aimed to increase the validity and reliability
of the research and ensure that the findings were interpreted within the appropriate context.
Furthermore, I believed that this study provided valuable insights into the topic of study and
served as a foundation for future research.
Recommendations for Future Research
To advance military BH research, future studies should longitudinally assess the effects
of recommended strategies on the recruitment, retention, and overall effectiveness of BH
providers within the Navy. These assessments should include tracking changes in recruitment
and retention rates, job satisfaction levels, and service delivery outcomes. Additionally,
exploring the experiences of BH providers and service members post-implementation can
provide insights into the mechanisms through which strategies impact individual well-being and
organizational outcomes. Furthermore, research should investigate the potential of emerging
technologies, such as AI and telehealth, in enhancing mental health services. Assessing the
efficacy and acceptability of AI-driven decision support systems and expanded telehealth

104
platforms can inform evidence-based policies and practices. Addressing the limitations of past
studies, such as the need for larger and more diverse samples and exploring the experiences of
different specialties within the military healthcare system should also be prioritized. Adopting a
comprehensive approach, future research endeavors can significantly contribute to improving
military BH practices and the well-being of service members.
Implications for Equity
The implications of this study align with the mission of USC Rossier School of
Education, which is committed to advancing educational equity and access for all (USC Rossier
School of Education, n.d.). Similarly, the study underscores the importance of equitable access to
mental health care for all Navy personnel, regardless of their location. By implementing the
recommended strategies, such as leveraging emerging technologies and expanding telehealth
services, the Navy can effectively bridge the gap in access to mental health care for service
members in remote or underserved areas (USC Rossier School of Education, n.d.). This
proactive approach not only promotes the overall well-being and readiness of service members
but also aligns with USC Rossier's mission to ensure that all individuals have equal opportunities
to thrive and succeed. Thus, by addressing disparities in mental health care access, the Navy can
uphold principles of equity and inclusivity, fostering a healthier and more resilient military
community.
Conclusion
When I enlisted in the Navy in January 2004, we proudly held the title of the "world's
finest Navy." However, in the years to come, should another industrialized nation such as China,
Russia, or India claim that title, it will likely be due to the critical shortage of BH providers and
the subsequent impact on our fleet's readiness. This potential shift will not stem from equipment

105
failures, lack of training, or resource deficiencies, but rather from a challenge that strikes at the
core of our operational effectiveness. While this perspective is informed by my two-decade
career in Navy healthcare, it is rooted in a broad range of professional experiences—from
serving as a combat hospital corpsman with the United States Marine Corps, providing frontline
medical care during operations, to a trained parachutist prepared for rapid deployment, a field
medical instructor training corpsmen and other medical personnel for deployment, to working as
a Navy substance abuse counselor, supporting Sailors in overcoming addiction challenges, and
now as a civilian healthcare administrator within the mental health department of one of the
largest Naval hospitals globally. In my current role, I have observed firsthand the significant
challenges posed by the shortage of BH providers. The perceived stigma around mental health
that I encountered as a young Sailor has significantly diminished, if not disappeared entirely.
Sailors and their families now demonstrate a much greater willingness to seek BH services,
reflecting a positive cultural shift within the Navy (Millegan et al., 2020).
The problem of practice was clearly articulated, a comprehensive literature review
conducted, a robust methodology architected, and interviews were executed with rigor and
diligence. The findings reveal that the shortage of BH providers within the Navy is not a minor
inconvenience but a critical issue threatening operational readiness and morale. This shortage has
far-reaching implications, affecting not only the Navy but also the broader national defense
capabilities and the mental health of service members and their families (Meadows et al., 2018;
NHOF, 2022).
The shortage of BH providers directly impacts the Navy's operational readiness. The
overwhelming workload and burnout experienced by existing BH providers significantly impair
their capacity to meet patient needs and accept new patients. Providers who participated in the

106
study claimed that they often feel like "glorified case managers" due to the high administrative
burden, which reduces their ability to offer quality care. The shortage has led to rushed and
fragmented care, with some patients falling through the cracks due to miscommunications and
administrative errors. Participants described feeling overwhelmed and unable to provide the level
of care they aspire to, highlighting the urgent need for systemic improvements to ensure
consistent and effective care.
As we move forward, it is imperative that the Navy and the broader defense community
take decisive action to address the shortage of BH providers, a significant threat requiring urgent
attention and action. A comprehensive approach underscores the need for immediate and
sustained efforts to recruit and retain BH providers, addressing administrative bottlenecks,
enhancing recruitment incentives, and expanding telehealth services. These measures will
improve access to care and ensure that service members receive timely and appropriate
treatment, thereby safeguarding the Navy's operational readiness and the well-being of its
personnel (Milegan et al., 2020). By implementing strategies such as competitive compensation,
a supportive workplace environment, and advanced technological solutions like telehealth, we
can ensure that the Navy remains the world's finest and that our Sailors and their families receive
the BH support they deserve (Donovan, 2020b; Cisneros, 2022a). The health and readiness of
our Sailors and their families are paramount to the strength and security of our nation. The future
of our Navy and the security of our nation depend on it.

107
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Tables
Table 1
Readiness Categories and Definitions
Term Definition
FMR Fully medically ready: service member is up to date on all medical/dental
requirements and is "deployable" or "deployable with limitations."
PMR
Partially medically ready: service member lacks one or more of the following:
an annual health assessment, immunizations, laboratory studies, or individual
medical equipment like prescription glasses.
NMR Not medically ready: service member is "temporary non-deployable" or
"permanent non-deployable" due to medical reasons.
TFMR Total Force Medical Readiness: the military branch’s specific percentage of
deployable members (FMR and PMR).
Table 2
Demographic Information of Participants
Pseudonym Status Position level Gender
C1 Civilian Staff Male
C2 Civilian Staff Female
C3 Civilian Staff Female
C4 Civilian Supervisor Male
C5 Civilian Staff Male
C6 Civilian Supervisor Female
N1 Active-Duty Supervisor Female
N2 Active-Duty Supervisor Female
N3 Active-Duty Staff Female
N4 Active-Duty Supervisor Male

121
N5 Active-Duty Staff Female
N6 Active-Duty Supervisor Female
Table 3
Interview Questions
Interview questions RQ Addressed
1. What drove you to work for this organization? Icebreaker
2. Are you finding that working as a BH provider here is everything you
thought it would be? How so? Icebreaker
3. What are your thoughts on the current shortage of BH providers in the
Navy? Icebreaker
4. What do you think the number one factor is for the shortage of BH
providers in the Navy? Probe: What, if any, are other factors that
might be contributing to the shortage given your experience?
2
5. In what ways, if at all, does the shortage of Navy BH providers impact
your ability to meet the needs of your existing patients and your ability
to accept new patients? Probe: Can you share any specific examples?
1
6. How, if at all, does the shortage of BH providers impact patient care in
your work environment? Probe: Can you share any specific examples? 1
7. What, if any, are the barriers or challenges to the Navy hiring
process/recruitment process for civilians? Probe: Can you elaborate on
what these barriers or challenges are in greater detail?
2
8. Can you describe the obstacles or difficulties that you have observed,
encountered, or heard of for uniformed BH providers, such as issues
related to deployments, training, duty, or other military obligations?
And how about for Civilians? Probe:
1
9. Hypothetically, if you heard of a colleague quitting, what would you
think the most likely reason would be? 1
10. Ideally, what could be done to increase the number BH providers in
the Navy? Probe: Can you elaborate on any specific initiatives or
programs that you think would be most effective in attracting and
retaining BH providers in the Navy?
2
11. Can you describe how the Navy's organizational structure impacts the
role and performance of BH providers?
2
12. Where in the geographical United States would you say the Navy has
the easiest time hiring BH providers? Where might you think it would
be the hardest?
2
13. Some people would say that employing more paraprofessionals like
substance abuse counselors and psychiatric health technicians would
help mitigate the shortage of BH providers. What are your thoughts?
3

122
Interview questions RQ Addressed
14. Besides an increase in hiring or recruiting, what else do you think can
be done to provide the best BH treatment to Navy beneficiaries despite
the shortage?
3
15. Is there anything further you would like to contribute to this study? None
Interviewer Script
That concludes our interview. I would like to thank you again for your time and for
sharing your experience with me.
*Stop recording

123
Appendix A: Interview Protocol
Interviewer Script
Hello, ________________, my name is Michael Ortiguero, and I am a doctoral student at the
University of Southern California. This interview is part of my efforts to obtain a Doctor of
Education in Organizational Change and Leadership. Thank you for taking the time out of your
busy schedule to participate in this study, it is greatly appreciated. The purpose of this study is to
explore the perspectives of behavioral health (BH) providers regarding the factors contributing to
the shortage of BH providers in the Navy. Additionally, the study will investigate potential
solutions for increasing BH treatment in the Navy, given the global shortage of providers. Your
participation is essential in achieving the goals of this study. Thank you for consenting to
participate. Please note that your involvement in this study is voluntary and you may end the
interview at any time. To maintain anonymity, pseudonyms will be used for your name and the
name of the hospital where you work. The interview will be recorded for research purposes. Do

124
Appendix B: Recruitment Flyer

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Asset Metadata

Creator Ortiguero, Michael Jacob (author)

Core Title An examination of factors that contribute to the shortage of behavioral health providers in the United States Navy

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Degree Conferral Date 2024-08

Publication Date 08/27/2024

Defense Date 07/22/2024

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